Arthroscopic foveal repair of the triangular fibrocartilage complex

Clinical Outcomes and Failure Rate of Triangular Fibrocartilage Complex Foveal Repair Were Comparable between Arthroscopic and Open Techniques

Background: This study compared clinical outcomes between arthroscopic and open repair of triangular fibrocartilage complex (TFCC) foveal tears in chronic distal radioulnar joint (DRUJ) instability patients. Methods: A total of 79 patients who had gone through foveal repair of TFCC using arthroscopic technique (n = 35) or open technique (n = 44) between 2016 and 2020 were retrospectively analyzed. The visual analog scale (VAS) score for pain, active range of motion (ROM), grip strength, Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and Patient-Rated Wrist Evaluation (PRWE) score at 2-4-6-12-24 months postoperatively were compared between two groups. Results: Two years after the operation, clinical parameters (VAS, MMWS, DASH, and PRWE), grip strength, and ROM showed significant advancement in the two groups in comparison to their values measured preoperatively (p < 0.001). Nonetheless, we could not identify any statistically significant differences in the above clinical factors between the two groups. The arthroscopic group showed a better flexion-extension arc at 2 months and supination-pronation arc at 2 and 4 months than the open group (p < 0.001). There were no significant differences between the two groups at 2 years postoperatively. Ten patients (12.6%) had recurrent instability (three in the arthroscopic group and seven in the open group, p = 0.499). Similarly, both groups showed no significant difference in the return to work period. Conclusions: Arthroscopic foveal repair of TFCC provided similarly favorable outcomes and early recovery of pain and ROM compared to open repair.

Current concepts and new trends in management of isolated triangular fibrocartilage complex injuries

The triangular fibrocartilaginous complex is made of multiple components, of which the palmar and dorsal radioulnar ligaments play an important role in distal radioulnar joint stability. The ulnar wrist ligaments may be injured during forearm and wrist trauma. There are several aspects of triangular fibrocartilaginous complex management that are still open to debate. The aim of the present study was to review the current concepts and discuss emerging trends to better elucidate and treat this important ligament complex.Level of evidence: V.

An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple

Traumatic foveal tears of the triangular fibrocartilage complex lead to ulnar-sided wrist pain and instability, resulting in painful motion and loss of grip strength with a severe impact on the overall function of the upper limb. Surgical repair is nothing new and has traversed through the realm of open repair to arthroscopic assisted to all arthroscopic repair techniques over the many decades, with arthroscopic repairs showing better visualization, lesser trauma, and equally favorable patient outcomes. Techniques had varied from using trans osseous tunnels to bone anchors, with or without the usage of special jigs. Here, we describe a simple and fast 3 portal arthroscopic technique of repairing the torn foveal insertion of the triangular fibrocartilage complex using a bone anchor inserted under arthroscopic and fluoroscopic guidance into the fovea. Both the dorsal and volar limbs of the triangular fibrocartilage complex are repaired arthroscopically, resulting in a strong anatomic repair resulting in a stable and pain-free wrist.

A Modified Arthroscopic Ulnar Tunnel Technique for Combined Foveal and Capsular (All-Inside) Fixation of Triangular Fibrocartilage Complex Injury

Background  Traumatic disruption of the triangular fibrocartilage complex (TFCC) is commonly present in various wrist traumas. A variation of surgical techniques is previously developed for different injury patterns. To our knowledge, only a few studies have investigated the fixation of combined foveal and capsular TFCC injuries using the ulnar tunnel technique. Purpose  This prospective cohort study of 21 patients aimed to evaluate the clinical and patient-reported outcome at 2 years of follow-up after arthroscopic TFCC of combined, foveal, and capsular reattachment by modified ulnar tunnel technique. Methods  Pain, grip strength, wrist motion, inclusive rotation, and patient-reported outcomes were assessed pre- and postoperatively at 2 years of follow-up. Results  No complications occurred preoperatively. Pain and patient-reported outcomes improved significantly ( p  < 0.0001 and 0.004). Grip strength improved, but not significantly ( p  = 0.088). The range of motion remained unchanged. All the patients achieved full stability of the distal radioulnar joint. Two patients sustained a new TFCC injury due to a wrist trauma and underwent a reoperation successfully. Two patients experienced complications: one patient experienced tenderness caused by cyst occurrence after PushLock ankers and the second had subluxation of the extensor carpi ulnaris tendon subsheet. Both patients were successfully treated and reoperated on with curettage of the cyst, and reconstruction of the extensor carpi ulnaris retinaculum. All the patients ended with good or excellent satisfaction scores. Conclusion  The ulnar tunnel technique for combined foveal and capsular injuries shows promising short-term follow-up results and high satisfaction scores in the patients. Level of Evidence  II (Prospective Corhorte).

Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review

BACKGROUND

Currently, there were two major surgical methods for arthroscopic triangular fibrocartilage complex (TFCC) foveal repair: suture anchor (SA) and transosseous suture (TOS). The purpose of this systematic review is to examine the relevant outcome improvement and safety of SA and TOS technique.

METHODS

Literature review of electronic databases for studies investigating the effects of SA and TOS in patients undergoing arthroscopic TFCC foveal repair was performed. We compared the pre-operative and postoperative functional outcomes, clinical outcomes [pain, range of motion (ROM) and grip strength], and complications of two methods. Minimal clinically important difference (MCID) was used to determine clinically meaningful improvement.

RESULTS

There were 1263 distinct studies identified, with 26 (904 patients) meeting the inclusion criteria. The mean age of participants ranged from 21.4 to 41 years, and the mean follow-up time ranged from 6 to 106 months. Both SA and TOS groups reported significant improvement in the modified mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, quick DASH score, patient-reported wrist evaluation (PRWE) score, and the visual analog scale (VAS) score. According to MCID, all the studies from both groups reporting DASH, quick DASH, PRWE and VAS score achieved clinically meaningful improvement. (MCID: 10 for DASH, 14 for quick DASH, 14 for PRWE and 1.6-18 for VAS). The ROM changes in both groups varied from improvement to deterioration. Grip strength improved in both SA and TOS group. Most complications were self-limited. The reoperation rates in SA and TOS ranged from 0 to 20% and 0 to 27.3%, respectively.

CONCLUSIONS

Both SA and TOS technique for arthroscopic TFCC foveal repair could achieve improvement in postoperative functional outcomes, pain, and grip strength with low reoperation rate. However, the ROM improvement was still inconclusive.

LEVEL OF EVIDENCE IV

Systematic review of level III and IV studies.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint

BACKGROUND

Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget).

PURPOSE

In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury.

STUDY DESIGN

This was a prospective cohort study.

METHODS

Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five.

RESULTS

Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Outcome in TFCC repair using micro anchor and trans‑osseous technique

The triangular fibrocartilage complex (TFCC) is an intrinsic stabiliser of the distal radioulnar joint (DRUJ), which serves an important role in wrist movement, forearm rotation and grip strength. A stable DRUJ is a key requirement for pain-free movement of the wrist. TFCC tears are a common ulnar-sided wrist pain associated with decreased grip strength and impaired function. TFCC tears are classified according to the location and cause. The Palmer classification delineates tears into traumatic type 1 and degenerative type 2. The present study investigated the clinical outcomes of using micro suture anchors in open repair in comparison with trans-osseous TFCC repair. From July 2017 to July 2020, 51 patients underwent open repair of TFCC tear by hand and upper limb surgeons in Royal Rehabilitation Center at King Hussein Medical Center (Amman, Jordan). Stability of DRUJ and tenderness at the ulnar aspect of the wrist were evaluated by Disability of the Arm, Shoulder and Hand (DASH) and Modified Mayo Wrist Score (MMWS) pre- and post-operatively. A total of 38 patients (27 male and 11 females) underwent open repair using micro suture anchors and 13 (7 male and 6 female) by trans-osseous repair. A total of 51 patients in the follow-up 6-48 months had significant improvement in pain and range of motion. A total of 45 patients showed improved grip strength and were pain-free; six patients showed improvement of grip strength and decreased pain. For the patients who underwent TFCC repair by micro suture anchors, there was an improvement of MMWS from 70 to 90%, and for those who underwent TFCC repair by trans-osseous technique, MMWS improved from 65 to 85%. There was also significant improvement in DASH score post-operatively with both techniques, from 60 to 15% in the trans-osseous technique and from 70 to 15% in the suture anchors. Open repair of TFCC tears using either micro anchor or trans-osseous repair led to pain-free range of motion, improved grip strength, stable DRUJ and improvement in DASH and MMWS scores, with no significant differences in clinical outcome between techniques.

Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.

Comparative Analysis of Treatment Outcomes: Modified Ulnar Gutter Slab vs. Sugar Tong Slab for Distal Radioulnar Joint Instability Following Triangular Fibrocartilage Complex Repair

The standard treatment for distal radioulnar joint (DRUJ) instability involves repairing the triangular fibrocartilage complex (TFCC) and immobilizing the joint with a sugar tong slab, but this can cause elbow stiffness. To address this, a modified ulnar gutter slab was designed to enhance elbow mobility during immobilization. A prospective randomized controlled trial was conducted on 23 DRUJ instability patients who underwent arthroscopic TFCC repair. Two post-operative splinting techniques were compared: the modified ulnar gutter slab and the sugar tong slab. The assessment included the Disabilities of Arm, Shoulder, and Hand (DASH) score; elbow, forearm, and wrist range of motion (ROM); post-operative DRUJ stability; and complications. DASH scores at 4 and 6 weeks were not significantly different. However, the modified ulnar gutter slab improved elbow extension range of motion at 4 weeks (extension lag: 20.0 vs. 6.5 in the sugar tong group) (p = 0.011). Post-operative DRUJ stability was comparable between the two groups. Notably, one patient in the sugar tong slab group experienced complex regional pain syndrome (CRPS). The modified ulnar gutter slab offers a post-operative alternative after TFCC repair. It effectively immobilizes forearm and wrist motion while enhancing elbow mobility, potentially reducing post-operative elbow stiffness.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists

BACKGROUND

Following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no "gold standard" rehabilitation protocol currently exists.

PURPOSE

To describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery.

STUDY DESIGN

Cross-sectional descriptive study.

METHODS

All Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05.

RESULTS

Survey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from "not required" to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from "immediately" to "later than 8 weeks," with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated "Yes." The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm.

CONCLUSIONS

Rehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

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.

Advances in the Repair of Palmer type IB TFCC Injuries With Wrist Arthroscopy

The triangular fibrocartilage complex (TFCC) is essential for maintaining wrist stability. Injury-caused pain is the primary cause of ulnar wrist pain. The TFCC injury refractory to conservative treatment requires further surgical treatment, and because Palmer type IB tears belong to peripheral injuries due to their proximity to the blood supply area, arthroscopic suture repair has become the preferred surgical method for TFCC injury repair, exhibiting strong healing ability. This study reviewed the anatomy of TFCC, injury classification, and advances in arthroscopic suturing for treating Palmer type IB.

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.

Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions

Distal radioulnar joint instability is a common clinical condition that can be either acute or chronic. Its management requires extensive knowledge of all the anatomical structures around the wrist area. The clinical examination must identify all damaged structures in order to define a customized reconstruction strategy. The aim of treatment is to prevent the development of chronic instability and/or arthritic lesions, which can only be treated with palliative surgery. Distal radioulnar instability is complex. Its management shares similarities with that of knee instability, with a wide range of conditions ranging from a sprain with isolated ligament tear to complex dislocation in which multiple ligaments are torn. In particular, the triangular fibrocartilage complex, which is a pillar of distal radioulnar joint stability, is not the sole stabilizer of this joint. The treatment strategy is not as simple as just reattaching this ligament to treat all of the acute and chronic clinical signs. The goal of the present study is to describe the various structures and possible lesions in this joint and then how to repair them. The diagnostic and therapeutic difficulties justify treatment at a specialized center.

A modified arthroscopic ulnar tunnel technique for foveal triangular fibrocartilage complex injury

Arthroscopically assisted techniques for the treatment of foveal triangular fibrocartilage complex (TFCC) injuries offer a less invasive option. Reports of the ulnar tunnel technique on a larger patient population are needed. This prospective cohort study of 44 patients aimed to evaluate the clinical and patient-reported outcome after arthroscopic foveal re-attachment using a novel, modified ulnar tunnel technique. Furthermore, preoperative magnetic resonance imaging findings were compared with the findings from the arthroscopic evaluation. History of ulnar sided wrist pain, positive fovea-sign at the clinical examination and positive hook test at the surgery were the main inclusion criteria for the study. Pain, grip strength, wrist motion and patient-reported outcomes were assessed pre-and postoperatively. The follow-up of this study was 31 months (range 18-48). No complications occurred during the surgery. All outcomes improved besides the range of motion, which remained unchanged. Pain on a visual analogue scale was 63 before, and 14 after the surgery (p = .0004). Pre- and postoperative values of Disability of Arm, Shoulder and Hand Questionnaire were 41/6, respectively (p = .007). Grip strength, measured in Kilogram-force were 29 and 36, pre-and postoperatively (p = .0004). Conspicuously, all patients achieved stability. Six patients needed re-operation, three for renewed injury. Thirty-nine of 44 patients scored excellent or good on the satisfaction score. We found the devised method to be with fewer complications and with favourable results compared with other techniques for the treatment of TFCC injuries. Level of evidence: III.

Arthroscopic foveal repair with suture anchors for traumatic tears of the triangular fibrocartilage complex

Background

Foveal tears of the traumatic triangular fibrocartilage complex (TFCC) are the most commonly neglected high-energy injuries of the wrist joint, and the patients with such tears often experience unrecovered ulnar-sided wrist pain and poor wrist function. This study investigated the functional outcomes of patients who underwent arthroscopic repair of foveal TFCC tears with suture anchors and adjuvant platelet-rich plasma (PRP) injections after the surgery.

Methods

From September 2014 to August 2018, 156 men and 45 women with diagnoses of foveal TFCC tears without wrist fractures underwent arthroscopic repair by using the outside-in method with 1.3-mm suture anchors and subsequent PRP injection. After surgery, splinting was applied for 6 weeks, and the patients underwent rehabilitation, re-examination, and follow-up at our clinic. The patients’ wrist functional scores and grip strength data were retrospectively collected.

Results

The mean follow-up period was 32.6 months, and the mean age was 26.7 years. The mean modified Mayo wrist score improved from 48.5 ± 2.6 to 82.4 ± 2.5, whereas the mean Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 39.2 ± 6.7 to 10.6 ± 7.5. Overall, the wrist functions of 186 (92.5%) of the patients were satisfactory according to their modified Mayo wrist scores, and the patients with satisfactory scores returned to sports or work activities. These patients retained normal ranges of motion, and their average grip strength in the affected hand was restored to at least 85% of that of the other hand.

Conclusions

According to the postoperative 25–36 months surgical results of our study, arthroscopic repair with adjuvant PRP injections is a satisfactory method of repairing early foveal tears of the TFCC and can enhance wrist function by relieving pain and increasing tolerance for work or sports.

Arthroscopically-Assisted Foveal Repair of the Triangular Fibrocartilage Complex: Anchor Fixation versus Trans Osseous Tunnel – A Comparative Study

Introduction The triangular fibrocartilage complex (TFCC) plays a fundamental role in the stability of the wrist, and its foveal insertion is the primary structure that performs this function. Surgical repair of the CFCT is challenging given the complexity of the anatomical structures, and arthroscopically-assisted reinsertion has shown certain benefits. The most commonly used techniques are reinsertion with anchors (RAs) and transosseous tunnels (TOs).

Objective To compare the functional results of patients with acute foveal lesion of the CFCT operated through RAs versus TOs, both with arthroscopic assistance.

Materials and methods A retrospective, observational study of patients operated on for foveal disinsertion of the TFCC. We included patients older than 18 years of age, with a traumatic history and conservative treatment lsting 3 months, with persistent pain and arthro-computed tomography (arthroCT) compatible with foveal disinsertion of the TFCC. Patients treated with the RA technique versus TOs were compared, both with arthroscopic assistance. The variables studied were pain during load according to the visual analog scale (VAS), Mayo score, and ranges of motion of the wrist. Values of p <0.05 were considered statistically significant.

Results We included 24 patients (11 in the RAs group and 13 in the TOs group) With an average age of 28.5 years, 58% of whom were male, without statistically significant differences between the groups. In the whole sample, a decrease in pain of 4.33 points (standard deviation [SD]: 1.16) on the VAS was found, with no statistically significant differences between the groups (p = 0.98). The Mayo score improved in both groups, with an average of 30.09 points (SD: 0.94) in the RAs group, and 31.92 points (SD: 1.32) in the TOs group, and this difference was statistically significant (p = 0.0004). Flexion-extension increased by 5.2° (SD: 2.3°) in the RAs group, and by 6.9° (SD: 1.32°) in the TOs group, and this difference was also statistically significant (p = 0.01). Pronation improved by 15.9° (SD: 1.7°) in the RAs group, and by 15.8° (SD: 1.72°) in the TOs group, which was not statistically significant (p = 0.46), and supination improved by 17.09° (SD: 2.46°) in the RAs group, and by 17.5° (SD: 1.61°) in the TOs group, which was statistically significant (p = 0.004).

The mean duration of ischemia was of 34.2 minutes (SD: 4.36 minutes) in the TOs group, and of 78.9 minutes (SD: 9.39 minutes) in the RAs group, and this difference was statistically significant (p = 0.000).

Discussion In the surgery for foveal reinsertion of the TFCC, both the techniques with anchors and with TOs, are effective in reducing load-bearing pain, improving the ranges of motion of the joints and the functional score. Although we found statistically significant differences between the groups regarding the Mayo score, flexion-extension and supination, these do not exceed the minimally-significant clinical differences.

Conclusion Both techniques are effective in reducing weight bearing pain and improving function and range of motion of the wrist. TO surgery has a significantly shorter ischemia time than RA surgery.

Open Foveal Repair of the Triangular Fibrocartilage Complex Tears Associated with Symptomatic Ulnar Styloid Non-union

Background: Symptomatic ulnar styloid non-union can be treated by excision of the ulnar styloid fragment. For combined triangular fibrocartilage complex (TFCC) tears, several repair techniques such as arthroscopic repair, open repair to the fracture site or reconstruction using a tendon graft have been introduced. This study reports the technique and outcomes of open foveal repair of the TFCC with excision of the ulnar styloid fragment in patients with symptomatic ulnar styloid non-union and distal radioulnar joint (DRUJ) instability. Methods: Consecutive patients with symptomatic ulnar styloid non-union with TFCC tears and DRUJ instability who underwent excision of the ulnar styloid fragment and open foveal repair of the TFCC were retrospectively reviewed. After excising the ulnar styloid fragment, a capsular window was created between the triquetrum and TFCC, followed by attaching the TFCC to the fovea using three sutures through a bone tunnel from the ulnar cortex to the fovea. Additional ulnar shortening osteotomies were performed in patients with positive ulnar variance and ulnar impaction test. The outcomes were evaluated in terms of DRUJ stability and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: In total, 21 patients with a mean age of 40 were enrolled in the study. All patients demonstrated DRUJ stability at a mean follow-up duration of 14 months. The mean Quick DASH score significantly improved from 18.9 ± 11.7 to 2.5 ± 4.1 (p < 0.05). Eleven patients underwent combined ulnar shortening osteotomies, and no difference in the Quick DASH score was found between patients who underwent ulnar shortening osteotomy and those who did not. Conclusions: This study demonstrates that open foveal repair of the TFCC with ulnar styloid fragment excision is an effective strategy to surgically treat patients with symptomatic ulnar styloid non-union with TFCC tear and DRUJ instability. Level of Evidence: Level III (Therapeutic).

Arthroscopic one-tunnel transosseous reconstruction of chronic triangular fibrocartilage complex foveal tears: outcomes in 12 patients

We report the surgical method and outcomes of a simple arthroscopic-assisted technique of repairing triangular fibrocartilage complex (TFCC) foveal injuries in 12 patients with chronic distal radioulnar joint instability. An ulnar transosseous tunnel was created with its distal exit point located 3 to 4 mm radial to the fovea. A tendon graft was cut into two parts, and both were then passed through the bone tunnel to secure the radioulnar ligament remnants back to the fovea in a 'V' shape configuration. At the final follow-up of 13 to 26 months (average 21), all patients had a reduction of wrist pain, with the mean visual analogue scale dropped from 4.6 to 1.6 out of 10. The distal radioulnar joint was completely stable in nine patients and had improved stability in three patients. The mean Mayo modified wrist scores improved from 72 to 89, and the clinical outcomes were excellent in four patients, good in seven and fair in one. No major surgical complications occurred. This simple arthroscopic one-tunnel transosseous approach is effective for chronic foveal tears of the TFCC with intact radioulnar ligament remnants.Level of evidence: IV.

Grip Strength Measurement for Outcome Assessment in Common Hand Surgeries

Grip strength has been used to evaluate the upper extremity functional status and clinical outcomes following upper extremity trauma or surgery. Understanding general recovery patterns of grip strengthening can be helpful in assessing the patients’ recovery status and in assisting in preoperative consultations regarding expectations for recovery. We summarize related studies on grip strength measurement and recovery patterns in common hand conditions, including carpal tunnel syndrome, cubital tunnel syndrome, triangular fibrocartilage complex injury, and distal radius fractures.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review

STUDY DESIGN

Scoping review.

BACKGROUND

Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time.

PURPOSE OF THE STUDY

To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery.

METHODS

A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery.

RESULTS

No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported.

CONCLUSIONS

TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

The rein-type arthroscopic capsular suture for triangular fibrocartilage complex foveal tears: midterm results for 90 patients

We describe an arthroscopic rein-type capsular suture that approximates the triangular fibrocartilage complex to the anatomical footprint, and report the results at a minimum 12 month follow-up. The procedure involves two 3-0 polydioxanone horizontal mattress sutures inserted 1.5 cm proximal to the 6-R and 6-U portals to obtain purchase on the dorsal and anterior radioulnar ligaments, respectively. The two sutures work as a rein to approximate the triangular fibrocartilage complex to the fovea. Ninety patients with Type IB triangular fibrocartilage complex injuries were included retrospectively. The 12-month postoperative Modified Mayo Wrist scores, Disabilities of Arm, Shoulder and Hand scores and visual analogue scale for pain showed significant improvements on preoperative values. Postoperative range of wrist motion, grip strength and ultrasound assessment of the distal radioulnar joint stability were comparable with the normal wrist. The patients had high satisfaction scores for surgery. There were minor complications of knot irritation. No revision surgery for distal radioulnar joint instability was required. It is an effective and technically simple procedure that provides a foveal footprint contact for the triangular fibrocartilage complex.Level of evidence: IV.

Morphologic Characteristics of the Sigmoid Notch of the Distal Radius for Patients With Peripheral Triangular Fibrocartilage Complex Tear

The distal radioulnar joint (DRUJ) is stabilized by the bony anatomy of the contact surfaces. The authors analyzed the morphologic characteristics and radiologic parameters at the sigmoid notch of patients with a peripheral triangular fibrocartilage complex (TFCC) tear compared with asymptomatic patients. Preoperative axial computed tomography scans were reviewed for 76 wrists with peripheral TFCC injuries, including foveal avulsion, and 76 wrists of age- and sex-matched control subjects. The authors used axial computed tomography scans of the DRUJ to classify the patients into 4 groups according to the type of sigmoid notch, namely, flat face, ski-slope, C-type, and S-type. They also measured the tilting angle, depth, width of the sigmoid notch, and radioulnar ratio (RUR). Statistical analyses were performed with the chi-square test or paired t test (P<.05). The mean proportions of flat face, ski-slope, C-type, and S-type sigmoid notches among patients with peripheral TFCC injuries were 42%, 22%, 29%, and 7%, respectively, whereas those for the control group were 33%, 1%, 65%, and 1%, respectively (P<.05). The tilting angle was lower (TFCC injury, 84.5°; control, 86.2°; P<.05) and the RUR was significantly higher (TFCC injury, 0.67; control, 0.56) in the TFCC group, particularly for men (P<.05). Depth (TFCC injury, 1.0 mm; control, 1.3 mm; P>.05) and width (TFCC injury, 14.8 mm; control, 14.5 mm; P>.05) were similar between the groups. Patients with ski-slope or dorsally tilted sigmoid notches may be at greater risk for peripheral TFCC injuries. [Orthopedics. 2021;44(6):e729-e734.].

Comparative outcomes between all-inside arthroscopic suture anchor technique versus arthroscopic transosseous suture technique in patients with triangular fibrocartilage complex tear: a retrospective comparative study

Background

Triangular fibrocartilage complex (TFCC) has become an interest over the last few decades, discovering its understanding in anatomy, pathomechanism, biomechanics, and management in treatments. Currently, TFCC does not have a golden standard procedure, and not one surgical procedure is superior to the other. This study is to evaluate the comparative outcomes in TFCC patients that underwent either in all-inside arthroscopic suture anchors or the arthroscopic transosseous suture technique.

Method

From 2017 to 2019, 30 patients were analyzed. Eight patients were in an arthroscopic transosseous group and 22 patients were in an all-inside arthroscopic group. Comparison between patients’ flexion and extension range of motion (ROM), grip strength, and visual analog pain scale (VAS) preoperative and six-month follow-up were analyzed.

Result

There were significant increases in flexion ROM, extension ROM, and VAS between preoperative and postoperative in all-inside arthroscopic and arthroscopic transosseous. Only the all-inside arthroscopic group had a significant increase in grip strength. Postoperative flexion ROM had a significant difference between all-inside arthroscopic and arthroscopic transosseous.

Conclusion

Both the all-inside arthroscopic suture anchor technique and the arthroscopic transosseous suture technique are appropriate treatments to treat patients with TFCC. Both procedures have achieved the ultimate goal of improved longevity and optimal function.

Level of evidence

Level III; retrospective comparative cohort study.

Experience with Diagnosis and Management of Distal Radioulnar Joint Instability

Objective  The aim of this study is to review our cumulative experience with diagnosis and treatment of distal radioulnar joint (DRUJ) instability and to present our treatment algorithm. Materials and Methods  Retrospective review identified 112 patients who had 126 episodes of care for DRUJ instability at a single institution over a 21-year period. Those diagnosed acutely or subacutely were treated with immobilization of the wrist and elbow for 6 weeks, while those with chronic instability had anatomic reconstruction of the dorsal and palmar radioulnar ligaments with tendon autograft or an alternative arthroscopic treatment with our thermal annealing technique. Short-term treatment failures and surgical complications were recorded. Nonparametric statistical tests were used to analyze key long-term outcome measures including ulnar wrist pain and DRUJ stability indicated by the dorsopalmar stress test. Results  At mean 7-year follow-up, eight patients in the acute-injury cohort had statistically significant improvements in wrist pain and DRUJ instability ( p  < 0.001). In both the 22-patient anatomic reconstruction cohort and the 37-patient arthroscopically treated group, there were also statistically significant improvements in wrist pain and DRUJ stability ( p  < 0.001) at mean 9-year follow-up. The majority of patients in all three groups was satisfied with treatment outcome, though some required secondary procedures. Conclusion  Early clinical diagnosis of DRUJ instability using the dorsopalmar stress test provides an opportunity for effective nonsurgical treatment. For chronic presentation, we recommend our arthroscopic thermal annealing technique for mild or moderate instability and open anatomic reconstruction of the radioulnar ligaments for severe instability. Level of Evidence  This is a Level IV, therapeutic study.

Postoperative Imaging of Ulnar Wrist Pain

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review

INTRODUCTION

Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents.

MATERIALS AND METHODS

A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed.

RESULTS

The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7-19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation.

CONCLUSION

Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

The Volar Distal Radioulnar Portal in Wrist Arthroscopy: An Anatomical Study

Background  Advances in wrist arthroscopy and the emergence of novel surgical techniques have created a need for new portals to the wrist. The aim of this study was to define and verify the safety of the volar distal radioulnar (VDRU) portal. Description of the Technique  The VDRU portal is located ∼5 to 10 mm proximal to the proximal wrist crease, just on the ulnar edge of flexor carpi ulnaris tendon and radial to the dorsal cutaneous branch of the ulnar nerve. The ulnar styloid marks the distal point of the portal. Methods  An anatomical study was performed on 12 upper extremity specimens of 6 human cadavers. Iatrogenic injuries of neurovascular structures potentially at risk were assessed, and the distance from the portal to these structures was measured. Results  No iatrogenic injuries of the structures at risk occurred. Mean distances from the VDRU portal to the ulnar neurovascular bundle, the radial branch of the dorsal sensory branches of the ulnar nerve (DSBUN), and the ulnar branch of the DSBUN were 9.29 ± 0.26 mm, 8.08 ± 0.25 mm, and 10.58 ± 0.23 mm, respectively. There were no differences between left and right wrists. The distances from the VDRU portal to the ulnar neurovascular bundle and the ulnar branch of the DSBUN were significantly shorter in women; this distance was not less than 7 mm in any case. Conclusions  The VDRU portal is safe, reproducible, and facilitates the implementation of various techniques related to triangular fibrocartilage complex pathology.

All-arthroscopic repair of Atzei class II and III triangular fibrocartilage complex tears using the FasT-Fix suture device

Background

The study is aimed to propose an arthroscopic repair technique using a pre-tied suture device for peripheral TFCC (triangular fibrocartilage complex) tear with proximal component involvement.

Methods

Through a retrospective review in the medical records of patients who underwent unilateral arthroscopic repair for TFCC Palmer IB lesion between 2017 and 2019, 12 patients were arthroscopically diagnosed as proximal component tear and received more than 1 year follow-up postoperatively. The arthroscope was introduced from 6R portal to discriminate Atzei class II from III lesions by a “visualization test” and to supervise the repair procedure using pre-tied FasT-Fix suture device from 3-4 portal. Two poly-ether-ether-ketone (PEEK) blocks were further advanced along the device needle to finally seat outside the ulnar joint capsule, followed by gradually tightening the pre-tied suture loop until the TFCC periphery was securely repositioned and held stably.

Results

Operation time averaged 87 min. Hook test and DRUJ arthroscopy confirmed proximal component tear in all 12 wrists. Four patients were diagnosed to be Atzei class II lesion as full thickness tear of distal component was arthroscopically identified from 6R portal while the other 8 exhibited partial thickness tear and were categorized as class III lesion. Follow-up averaged 15 months with a range of 12 to 24 months. Mayo modified wrist score improved from an average of 61.3 preoperatively to 90.4 at the latest visit.

Conclusions

A modified technique for diagnosis and all-arthroscopic repair in TFCC Atzei class II and III lesions using a pre-tied suture device is a feasible and safe option with promising results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02046-1.

Short-term effect of electroacupuncture on rehabilitation after arthroscopic triangular fibrocartilage complex repair: a randomised study

Background

Electroacupuncture (EA) alleviates chronic pain and acute postoperative pain after several surgical procedures. However, whether EA facilitates postoperative functional recovery after arthroscopic surgery has yet to be determined. This study investigated the short-term effect of EA on a rehabilitation course after arthroscopic triangular fibrocartilage complex (TFCC) repair.

Methods

Forty-two patients undergoing arthroscopic TFCC repair were randomised to an EA group (n = 19) or control group (n = 23). In the EA group, patients received EA treatment and standard active rehabilitation for 4 weeks. In the control group, patients received standard active rehabilitation for 4 weeks. At the end of the treatment and at the follow-up visit 4 weeks after the treatment, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, wrist range of motion (ROM), handgrip strength, and key pinch strength were collected and analysed.

Results

The EA group improved significantly than the control group in terms of DASH scores, all wrist motion arcs, and key pinch strength (P < 0.05) at the end of the 4-week treatment and the follow-up visit another 4 weeks later.

Conclusion

Patients treated with 4 weeks of EA after the arthroscopic TFCC repair had better wrist ROM and DASH scores than patients of control group

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02361-1.

Arthroscopic ligament-specific repair for triangular fibrocartilage complex foveal avulsions: a minimum 2-year follow-up study

This study reports the arthroscopic ligament-specific repair of the triangular fibrocartilage complex (TFCC) that anatomically restores both the volar and dorsal radioulnar ligaments into their individual foveal footprints. Twenty-five patients underwent arthroscopic ligament-specific repair with clinical and radiological diagnoses of TFCC foveal avulsions. The mean age was 28 years (range 14-47) and the mean follow-up was 31 months (range 24-47). Following arthroscopic assessment, 20 patients underwent double limb radioulnar ligament repairs and five had single limb repairs. At final follow-up, there were significant improvements in wrist flexion-extension, forearm pronation-supination and grip strength. There were also significant improvements in pain and patient-reported outcomes as assessed by the patient-rated wrist evaluation, Disabilities of the Arm, Shoulder and Hand score and modified Mayo wrist scores. Arthroscopic ligament-specific repair of the TFCC does not require specialist dedicated equipment or consumables and offers a viable method of treating these injuries.Level of evidence: IV.

Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review

Objective  This study systematically reviews the outcomes of surgical repair of triangular fibrocartilage complex (TFCC) tears. Existing surgical techniques include capsular sutures, suture anchors, and transosseous sutures. However, there is still no consensus as to which is the most reliable method for ulnar-sided peripheral and foveal TFCC tears. Methods  A systematic review of MEDLINE and EMBASE was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The focus was on traumatic Palmer 1B ulna-sided tears. Twenty-seven studies were included, including three comparative cohort studies. Results  There was improvement in all functional outcome measures after repair of TFCC tears. The outcomes following peripheral and foveal repairs were good overall: Mayo Modified Wrist Evaluation (MMWE) score of 80.1 and 85.1, Disabilities of the Arm, Shoulder and Hand (DASH) score of 15.7 and 15.8, grip strength of 80.3 and 92.7% (of the nonoperated hand), and pain intensity score of 2.1 and 1.7, respectively. For peripheral tears, transosseous suture technique achieved better outcomes compared with capsular sutures in terms of grip strength, pain, Patient-Rated Wrist Evaluation (PRWE), and DASH scores (grip 85.8 vs. 77.7%; pain 1.5 vs. 2.2; PRWE 11.6 vs. 15.8; DASH 14.4 vs. 16.1). For foveal tears, transosseous sutures achieved overall better functional outcomes compared with suture anchors (MMWE 85.4 vs. 84.9, DASH 10.9 vs. 20.6, pain score 1.3 vs. 2.1), but did report slightly lower grip strength than the group with suture anchors (90.2 vs. 96.2%). Arthroscopic techniques achieved overall better outcomes compared with open repair technique. Conclusion  Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates. Level of Evidence  This is a Level IV, therapeutic study.

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.

Surgical Repair of Acute TFCC Injury

Triangular fibrocartilage complex tears are a common source of ulnar-sided wrist pain and distal radioulnar joint instability. Symptoms recalcitrant to conservative management or injuries in high-demand athletes may indicate surgical management. Both open and arthroscopic techniques offer improvements in objective measures, patient-centered outcome scores, and return to work, but may be complicated by nerve irritation, persistent wrist instability, and pain. Recently developed knotless arthroscopic techniques are not well studied but may limit morbidity.

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.

Transulnar Styloid Foveal TFC Reconstruction: With a Palmaris Longus Tendon Graft

We describe an evolution of the senior author's technique in the repair or reconstruction of foveal triangular fibrocartilage complex tears. This technique uses a transulnar styloid approach, which gives superior access to the fovea, without disruption of secondary stabilizers. A free palmaris longus graft is used to stabilize and augment the triangular fibrocartilage complex with an interosseous anchor through an ulnar tunnel.

Arthroscopic Ligament-specific Repair for Triangular Fibrocartilage Complex Foveal Avulsion: A Novel Technique

The deep components of the triangular fibrocartilage complex (TFCC), which consist of the volar and dorsal radioulnar ligaments (RULs), are crucial for maintaining stability of the distal radioulnar joint. Avulsion of the volar and dorsal RULs from their foveal insertions must thus be diagnosed and treated correctly. We describe our arthroscopic technique for TFCC foveal repair (arthroscopic ligament-specific transosseous repair), in which we repair each of the dorsal and volar RUL to separate points on the fovea. With this "ligament-specific" repair we wish to restore the normal anatomy and physiology of the TFCC.

The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist

Background

Triangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography.

Methods

One hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPR_Standard), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPR_Styloid) or in the ulnar fovea (MPR_Fovea). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer’s and Atzei’s classification and diagnostic confidence was stated on a five-point Likert scale.

Results

Compared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPR_Fovea: p < 0.001; MPR_Styloid: p ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPR_Standard 78.6%/80.4%, MPR_Styloid 94.6%/94.6%, MPR_Fovea 91.1%/89.3%) and accuracy (MPR_Standard 86.8%/86.8%, MPR_Styloid 96.2%/96.2%, MPR_Fovea 94.3%/93.4%) improved with additional styloid-centered (p = 0.004/0.008) and fovea-centered (p = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR (p = 0.688/0.250). Interrater agreement was almost perfect for each dataset (κ_Standard = 0.876, κ_Styloid = 0.894, κ_Fovea = 0.949). Diagnostic confidence increased with addition of either radial MPR (p < 0.001).

Conclusions

Ancillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

Wrist Arthroscopy in Athletes

Arthroscopy is a surgical technique whose indication for wrist injuries has grown in recent years. Athletes are subject to traumatic injury to the wrist due to training overload or the intensity of the activity during competition. The need of a quick return to sports practice makes arthroscopy a very useful minimally invasive technique in these situations. The authors present indications of sports-related injuries to the wrist that can be treated by arthroscopy. A literature review is also presented.

Outcome of conservative treatment for triangular fibrocartilage complex lesions with stable distal radioulnar joint

Purpose

Triangular fibrocartilage complex (TFCC) lesions have high clinical relevance. Although multiple studies have been done in the past, there is a lack of data after conservative treatment and controversy remains regarding management. The purpose of this study was to compare the outcome of symptomatic TFCC lesions after conservative treatment and arthroscopic debridement.

Methods

Between 2012 and 2017, 33 patients were included. 16 patients were treated conservatively and 17 patients with arthroscopic debridement. The average age was 41 years (range 18–63). The mean follow-up was 22.2 months (range 6–74). Evaluation included pain, range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Modified Mayo Wrist Score (MMWS), and Purdue Pegboard test.

Results

Pain averaged 0.1 (range 0–1) in the conservative group compared to 1.3 (range 0–6) in the arthroscopic group. The mean ROM was 99% for wrist extension, and 100% for flexion and pro-/supination in the conservative group, and 96% for extension and flexion, and 100% for pro-/supination in the arthoscopic group compared to the contralateral side. Grip strength was 88% (range 63–100) in the conservative group versus 89% (range 33–100) in the arthroscopic group. The conservative group reached a DASH score of 16.8 and MMWS of 94.3 compared to 22.1 and 87.2 in the arthroscopic group. The differences were not statistically significant.

Conclusions

Our study demonstrated similar results of conservative compared to arthroscopic treatment. Because conservative treatment was a sufficient and reliable option, we propose it as first-line treatment for TFCC lesions with stable distal radioulnar joint.

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.

Outcomes of ulnotriquetral split tear repair: a report of 96 patients

Ninety-six wrists (56 right and 40 left) in 96 patients (36 males and 60 females, mean age 38, range 15-77 years) underwent repair of ulnotriquetral ligament split tears between 2007 and 2016. Mayo wrist scores, visual analogue scale pain scores, and objective measures including grip strength and range of motion were obtained. Patients were assessed after a mean follow-up of 21 months (range 6-112 months). Ulnotriquetral split tear repair resulted in substantial improvements in pain and function. The mean Mayo wrist score improved from 57 preoperatively to 81 postoperatively, with 84% of patients achieving a good or excellent outcome. Pain scores decreased from 5.8 to 1.2. Grip improved from 25 kg to 29 kg. There was no significant change in range of motion of the wrist. Complications were noted in eight patients, with three experiencing continued pain, four with dysaesthesia of the dorsal sensory ulnar nerve, and one superficial infection. Arthroscopic ulnotriquetral split tear repair significantly reduced pain and improved Mayo wrist scores. Level of evidence: IV.

Designing a 20 mm incision to protect the dorsal branch of the ulnar nerve during arthroscopic repair of triangular fibrocartilage complex injuries: Cadaver study and preliminary clinical results

The ulnar-sided approach for arthroscopic peripheral triangular fibrocartilage complex (TFCC) repair may be associated with injury to the dorsal branch of the ulnar nerve (DBUN). The goal of this study was to develop a small incision to help minimize DBUN injury. Ten cadaveric upper limbs were used to measure the anatomic parameters of the DBUN. Based on these measured anatomical relationships, a 20 mm longitudinal incision with the ulnar styloid process as the midpoint was designed to explore and protect the DBUN. Three additional cadaveric upper limbs were used to test the feasibility of this method. Then this method was applied in 15 patients with TFCC injury (IB type). In 10 cadavers, the DBUN was located volar to the ulnar styloid process. The mean linear distance between the DBUN and the ulnar styloid process was 8.04 mm (range: 7.02-8.82mm) in the transverse-volar direction and 13.78 mm (range: 11.06-16.02mm) in the longitudinal-distal volar direction. In three additional cadavers, the DBUN was successfully explored and retracted with this incision, creating a safer space for passing sutures and tying knots. This modified method was used successfully in 15 patients, and the DBUN was protected during surgery. There were no complications, and most importantly, no injuries to the DBUN at the 6-month follow-up visit. Therefore, we recommend that a 20 mm longitudinal incision with the ulnar styloid process as the midpoint be made prior to passing sutures during the arthroscopic repair of TFCC tears to avoid injuring the various branches of the DBUN.

[Radiology of the distal radioulnar joint and the ulnocarpal complex]

X-ray images exposed in neutral position and radiocarpally centred are essential in imaging of the distal radioulnar joint (DRUJ). The anatomic orientation of the DRUJ is favourable for acquiring transaxial scans to display its anatomy, subtle derangements, osteoarthritis and intra-articular fractures free from superpositions. The triangular fibrocartilage complex (TFCC) is the most important stabilizer of the DRUJ. Provided that a focused clinical indication is given, high-resolution images are acquired, and an intra-venous or intra-articular contrast-agent is applied, all TFCC structures and destabilizing lesions can be displayed with the use of CT and MRI.

[Arthroscopy of the distal radioulnar joint]

OBJECTIVE

The aim of the procedure is to visualize the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar side surface of the triangular fibrocartilage complex (TFCC).

INDICATIONS

Arthroscopy of the distal radioulnar joint is applied for the evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X‑rays and MRIs and arthroscopically assisted procedures.

SURGICAL TECHNIQUE

In vertical extension, two portals of the wrist are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. By insertion of a small joint arthroscope via these portals visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ and the proximal surface of the TFCC is accomplished.

CONCLUSIONS

Arthroscopy of the DRUJ is a rarely and not routinely performed procedure for the diagnosis and therapy of ulnar-sided wrist pain. It is technical demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon, as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases, this procedure offers important additional information about the distal radioulnar joint. The procedure is especially valuable for the detection of proximal TFCC injuries that are missed otherwise.

Arthroscopic reduction of an irreducible distal radioulnar joint in Galeazzi fracture-dislocation due to a fragment of the ulnar styloid: a case report

Background

There are only a few published case reports of irreducible Galeazzi fracture-dislocation, and patients in these studies had undergone reduction by open surgical methods. Arthroscopy for the distal radioulnar joint of the wrist joint has recently been used for wrist pathology. We aim to describe the surgical procedure involved in arthroscopic reduction of irreducible Galeazzi fracture-dislocation and clinical outcome and review the literature.

Case presentation

We present the case of a 26-year-old man, a professional athlete, who sustained Galeazzi fracture-dislocation during a bicycle race. The distal radioulnar joint was irreducible because the fragment of the ulnar styloid was trapped between the sigmoid notch and ulnar head after a doctor had previously reduced it manually. Operative treatment was performed using a 30° oblique, 1.9-mm arthroscope. Reduction of the fragment of the ulnar styloid was achieved using distal radioulnar joint arthroscopy. The metaphyseal and intra-articular fracture of the radius and the fragment of the ulnar styloid were fixed using a volar locking plate and tension band wiring technique, respectively. A daily injection of parathyroid hormone and low-intensity pulsed ultrasound were used postoperatively. The patient was asymptomatic and returned to the preinjury level of athletic activity 2 months postoperatively, and bone union of the radius and ulna was achieved without distal radioulnar joint instability 15 months postoperatively.

Conclusions

Less invasive reduction of the dorsal anatomical structure enabled our patient to return early to sports. We consider arthroscopic reduction to be superior to the open surgical method in terms of evaluating interpositions; additionally, arthroscopic reduction is minimally invasive and does not need immobilization because it does not cause significant damage to the dorsal capsule and subsheath of the extensor carpi ulnaris, which comprise the triangular fibrocartilage complex.

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.