Degeneration Process of Symptomatic Central Tears in the Triangular Fibrocartilage

Degeneration of the articular disc in the human triangular fibrocartilage complex

INTRODUCTION

Traumatic injuries of the triangular fibrocartilage complex (TFCC) are frequent reasons for ulnar wrist pain. The assessment of the extent of articular disc (AD) degeneration is important for the differentiation of acute injuries versus chronic lesions.

MATERIALS AND METHODS

The AD of the TFCC of eleven human cadaver wrists was dissected. Degeneration was analyzed according to the grading of Krenn et al. Hematoxylin-eosin was used to determine the tissue morphology. Degeneration was evaluated using the staining intensity of alcian blue, the immunohistochemistry of the proteoglycan versican and the immunoreactivity of NITEGE, an aggrecan fragment.

RESULTS

The staining homogeneity of HE decreased with higher degeneration of the AD and basophilic tissue areas were more frequently seen. Two specimens were characterized as degeneration grade 1, five specimens as grade 2, and four specimens as grade 3, respectively. Staining intensity of alcian blue increased with higher degeneration grade of the specimens. Immunoreactivity for NITEGE was detected around tissue fissures and perforations as well as matrix splits. Immunoreactivity for versican was found concentrated in the tissue around matrix fissures and lesions as well as loose connective tissue at the ulnar border of the AD. Specimens with degeneration grade 2 had the strongest immunoreactivity of NITEGE and versican. Cell clusters were observed in specimens with degeneration grade 2 and 3, which were stained by alcian blue and immunoreactive for NITEGE and versican. Increasing age of the cadaver wrists correlated with a higher degree of degeneration (p < 0.0001, r = 0.68).

CONCLUSIONS

The fibrocartilage of degenerated ADs contains NITEGE and versican. The amount of the immunoreactivity of these markers allows the differentiation of degenerative changes into three grades. The degeneration of the AD increases with age and emphasizes its important mechanical function.

[Diagnosis and treatment of degenerative disc lesions of the wrist]

BACKGROUND

The triangular fibrocartilage complex (TFCC) widens the radiocarpal joint and takes part in load transmission from the carpus to the forearm. It is thereby prone to degenerative changes. The painful situation that can accompany degeneration is called ulnar impaction.

DIAGNOSIS

Clinical examination helps differentiate between various causes of ulnar-sided wrist pain. Standard X‑rays are needed to determine ulnar variance and stress radiographs can depict narrowing of the ulnocarpal joint space under load. MRI may prove degeneration of the TFCC itself or may indirectly confirm ulnar impaction in the presence of bone marrow edema in the ulnar head or at the proximal ulnar aspect of the lunate.

TREATMENT

If conservative treatment fails to alleviate symptoms, arthroscopy may be indicated. On the one hand, this completes the diagnostic cascade, and, on the other hand, allows decompression of the ulnocarpal joint space by resection of the TFCC with partial resection of the ulnar head (wafer resection). In the case of ongoing pain, ulnar shortening sufficiently alleviates ulnar-sided wrist pain. Thereby, modern standardized operation techniques are safe enough to ensure bone healing at the osteotomy site. The aim of alleviating ulnar-sided wrist pain is mostly achieved if the correct treatment option is chosen.

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.

Results after arthroscopic treatment of central traumatic lesions of the triangular fibrocartilage complex

INTRODUCTION

Injuries of the triangular fibrocartilage complex (TFCC) are of high clinical relevance; however, the clinical evidence for treatment is poor and long-term results are rarely published. The purpose of this study was to evaluate the clinical outcome of symptomatic central traumatic lesions of the TFCC (Palmer 1A) following arthroscopic debridement.

MATERIALS AND METHODS

Between 2007 and 2013, 87 patients were arthroscopically diagnosed with Palmer 1A lesion and accordingly treated with debridement. Follow-up was available for 43 patients. Activities of daily living (ADLs) were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Pain perception was evaluated with visual analogue scale (VAS 0-10). Grip strength and wrist motion were assessed with conventional techniques using a Jamar dynamometer and a goniometer. Patient satisfaction was assessed using a questionnaire at follow-up.

RESULTS

Mean follow-up was 42.5 months (range 5-70). The mean age of the patients (22 male and 21 female) at time of surgery was 41 ± 15.9 years. No major complication occurred during surgery and follow-up. The DASH score (preoperatively 49.8 ± 19.3 vs. postoperatively 14.1 ± 17.9, p < 0.05) and pain perception (VAS: preoperatively 7.2 ± 2.0 vs. postoperatively 1.4 ± 1.6, p < 0.05) improved significantly. Grip strength was satisfactory after surgery (19.6 ± 13.1). Ulnar deviation improved significantly from 29.3 ± 10.4° to 35.6 ± 8.3° (p < 0.05) and wrist flexion improved from 53.8 ± 18.9° to 67.4 ± 12.9° (p < 0.05). Wrist extension, radial deviation, pronation and supination did not change significantly after surgery. Improved symptoms were reported by 41/43 (95.3%) patients and 40/43 (93%) patients would have had the same procedure again knowing the final outcome. Six of 43 patients (15%) had an ulnar plus variance. None of these needed ulnar shortening.

CONCLUSIONS

Central traumatic TFCC lesions can safely be treated by arthroscopic debridement. We showed a sustained pain relief with significantly improved quality of life (DASH score) and wrist motion at follow-up. This resulted in a high patient satisfaction and acceptance of the procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, level IV.

Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy

This study examined the reliability of surgeons' estimations as to whether central lesions of the triangular fibrocartilage complex were traumatic or degenerative. A total of 50 consecutive central triangular fibrocartilage complex lesions were independently rated by ten experienced wrist surgeons viewing high-quality arthroscopy videos. The videos were reassessed after intervals of 3 months; at the second assessment surgeons were given the patient's history, radiographs and both, each in a randomized order. Finally, the surgeons assessed the histories and radiographs without the videos. Kappa statistics revealed fair interrater agreement when the histories were added to the videos. The other four modalities demonstrated moderate agreement, with lower Kappa values for the assessment without videos. Intra-rater reliability showed fair agreement for three surgeons, moderate agreement for two surgeons and substantial agreement for five surgeons. It appears that classification of central triangular fibrocartilage complex lesions depends on the information provided upon viewing the triangular fibrocartilage complex at arthroscopy.

LEVEL OF EVIDENCE

II.

[Standard wrist arthroscopy: technique and documentation]

OBJECTIVE

Minimally invasive approach to the wrist in order to diagnose and treat different wrist pathologies.

INDICATIONS

Diagnosis of unclear chronic pain syndromes, cartilage status, intra-articular ligament structures as well as post-traumatic and inflammatory conditions of the wrist. Treatment of ulnar impaction syndrome, dorsal ganglia and also in fracture treatment and various different wrist interventions.

CONTRAINDICATIONS

Soft tissue infections around the wrist, severe scarring may impede access to the joint.

SURGICAL TECHNIQUE

Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3-4 kg. Superficial stab incision, blunt preparation through joint capsule, insertion of optic through 3-4 portal and probe through 4-5 portal, and radial and ulnar midcarpal portals, respectively. Either sodium chloride, CO2 or air is used as arthroscopy medium. Diagnostic round with standardized examination of all parts of the joint. Standardized written and high quality photo and/or video documentation to facilitate understandability of the findings.

POSTOPERATIVE MANAGEMENT

Forearm cast for 1 week, limited load for 2 more weeks, then load is increased to normal.

Cartilage cell proliferation in degenerative TFCC wrist lesions

INTRODUCTION

The central zone of the triangular fibrocartilage complex (TFCC) of the wrist is thought to be avascular and is generally considered to lack any healing potential.

AIM

The purpose of this study was to investigate, if cartilage cells of degenerative disc lesions possess any healing or proliferation potential and whether ulna length plays a significant role in the proliferation process.

RESULTS

Cells positive for proliferating cell nuclear antigen (PCNA) were found in all specimens. Specimens of patients with ulna positive variance showed a decreased number of PCNA positive cells than specimens of patients with either negative or neutral ulna variance.

CONCLUSION

We found that cartilage cells of Palmer type 2C lesions undergo mitotic cell division, thus exhibiting proliferation capability. It could not be shown that ulnar length is significantly correlated with the number of PCNA positive cells.

Ulnar shortening after TFCC suture repair of Palmer type 1B lesions

PURPOSE

The objective of this study was to determine functional and subjective outcomes of an ulnar shortening procedure elected by patients who experienced persistent ulno-carpal symptoms following arthroscopic suture repair of a Palmer type 1B lesion. All patients had a dynamic ulna positive variance.

METHODS

Five patients (3 males and 2 females) with arthroscopic repair of Palmer type 1B tears who subsequently underwent ulnar shortening were reviewed. At the time of the arthroscopic repair the patients' average age was 37 +/- 13 years (range 16-52 years). Average time to follow-up was 14 +/- 6 months (range 10-23 months). The average age was 38 +/- 14 years (range 17-53 years) when the ulnar shortening was performed. The second follow-up took place 7 +/- 2 months (range 5-9 months) after ulnar shortening. During the follow-ups, range of motion, grip strength, pain, Modified Mayo Wrist Score, DASH Score, and ulnar length were evaluated. Citing persistent ulno-carpal symptoms, the patients elected ulnar shortening an average of 17 +/- 7months (range 13-29 months) following the arthroscopic repair. Prior to ulnar shortening the average static ulnar variance was 0.2 +/- 1.3 mm (range -1 to 2 mm), the average dynamic ulnar variance was 1.4 +/- 0.5 mm (range 1 to 2 mm).

RESULTS

Ulnar shortening brought about further reduction in pain after the arthroscopic repair of the triangular fibrocartilage complex (TFCC) had already reduced it. As measured by a visual analogue scale, the average value after ulnar shortening was 2.2 +/- 2.1 (range 0.7-5.0). The average static ulnar variance was -3.4 +/- 2 mm (range -5 to -1 mm). Patients were very satisfied with the results of the ulnar shortening and four out of five indicated that it had significantly improved their symptoms and they would elect ulnar shortening again. Postoperative range of motion as a percentage of the contralateral side averaged 90% for the extension/flexion arc, 80% for the radial/ulnar deviation arc, and 100% for the pronation/supination arc of motion. In addition, there was an improvement in grip strength. The Modified Mayo Wrist Score was rated excellent in three patients, and fair in two patients. The average DASH score was 22 +/- 22 (range 0-53).

CONCLUSIONS

Patients who have a dynamic ulna positive variance and experience persistent ulno-carpal symptoms following arthroscopic suture repair of a Palmer type 1B lesion, benefit from an ulnar shortening procedure. Shortening the ulna can improve these patients' symptoms of pain, range of motion, and grip strength.

Apoptotic pathways in degenerative disk lesions in the wrist

PURPOSE

Degenerative articular disk perforations of the triangular fibrocartilage (TFC) of the wrist could result from chronic loading of the ulnocarpal joint. Apoptosis played a crucial role in fibrocartilage cell loss, and the purpose of this study was to clarify which apoptotic pathway was involved in the development of degenerative disk lesions. We also investigated whether ulna length played an etiologic role in the occurrence of fibrocartilage cell loss.

METHODS

Included in the study were 17 patients with degenerative articular disk tears of the TFC (Palmer type 2C). After arthroscopic debridement of the TFC, histologic sections were examined to assess the presence of apoptosis. Apoptosis was determined by use of caspase 3, caspase 8, and caspase 9 immunohistochemistry. Furthermore, Fas ligand and BID (BH3 interacting domain death) agonist were applied for immunohistochemical analysis.

RESULTS

Cells positive for caspase 3, caspase 8, caspase 9, Fas ligand, and BID were found in all specimens. The number of cells positive for caspase 3 and BID was significantly increased in specimens from patients with an ulna-positive variance. In contrast, for cells positive for caspase 8, caspase 9, and Fas ligand, no significant difference was found between specimens from patients with an ulna-positive variance and those from patients with an ulna-neutral/ulna-negative variance.

CONCLUSIONS

The extrinsic and intrinsic apoptotic pathways are involved in the development of degenerative disk lesions. Fibrocartilage cell loss occurs mainly through the intrinsic apoptotic pathway. The accumulation of apoptotic cells is not significantly different between the 3 zones of the TFC. It could be verified that ulna length is correlated with fibrocartilage cell loss.

CLINICAL RELEVANCE

Ulnar shortening is a valuable treatment option for degenerative TFC lesions. Knowledge of the specific apoptotic pathway that is causing degenerative disk lesions is critical in selecting the appropriate and most beneficial therapeutic treatment to halt further cell loss and the degeneration of the TFC.

Incidence and distribution of blood vessels in punch biopsies of Palmer 1A disc lesions in the wrist

INTRODUCTION

Although the partial excision of triangular fibrocartilage complex (TFCC) tears appears to be a clinically effective technique, little is known about the ability of the central disc tears to heal. Unlike peripheral tears, central tears do not have immediate access to blood supply. The purpose of this study was to examine the incidence and distribution of blood vessels in punch biopsies of symptomatic central TFCC tissue. In addition, the study investigated if arthroscopic debridement can reach vascularized tissue to enable a reparative response of the tear.

MATERIALS AND METHODS

Thirty-two patients with symptomatic central traumatic tears in the TFCC (Palmer 1A) were included in this study. The cartilage was debrided arthroscopically using a biopsy punch. The debrided tissue was then examined histologically. To visualize blood vessels, the histological sections were stained with CD 31 antibodies. The presence/absence of blood vessels was recorded on a qualitative level.

RESULTS

In six patients, five or more blood vessels (CD31 positive endothelial cells) could be detected. In eight patients, fewer than five vessels could be found in the periphery of the slides. In 18 patients no vessels could be identified. The incidence of vessels in the outer region was higher than in the inner region of the peripheral area. There was no correlation found between the time of trauma and incidence of blood vessels (P > 0.05).

CONCLUSION

Only in 43% of arthroscopic debridements of Palmer 1A tears vascularized tissue could be reached.

Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears

PURPOSE

The objective of this retrospective study was to determine functional and subjective outcomes of patients with Palmer type 1B tears repaired arthroscopically and to investigate whether clinical outcomes are related to ulna length.

METHODS

Forty-six patients with arthroscopic repair of Palmer type 1B tears were reviewed. There were 23 males and 23 females. The average age was 34 years (range, 10 to 58 yrs). The average follow-up was 11 months (range, 6 to 23 mos), and the delay to surgery was 9.7 months. All patients suffered ulnar-sided wrist pain and were diagnosed with Palmer type 1B tears. The tear was repaired arthroscopically with an inside-outside suture technique. The range of motion (ROM), grip strength, pain, wrist score (modified Mayo wrist score), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) score, and ulna length (static and dynamic) were evaluated.

RESULTS

There was a reduction in pain and an improvement in grip strength. Postoperative ROM averaged 128 degrees +/- 23 degrees for the extension/flexion arc, 41 degrees +/- 11 degrees for the radial/ulnar deviation arc, and 171 degrees +/- 19 degrees for the pronation/supination arc of motion. However, no relation could be found between ulna length and clinical outcome. The modified Mayo wrist score was rated excellent in 22% of patients, good in 41%, fair in 27%, and poor in 10%. The average DASH score was 21.70 +/- 17.17 (range, 0 to 58.33).

CONCLUSIONS

Arthroscopic repair of Palmer type 1B tears yields satisfactory results. Sixty-three percent of patients achieved good to excellent results, experienced increased ROM, grip strength, and pain relief. Ulnar neutral or positive variance is not a contraindication for suture repair and does not require simultaneous ulna shortening when repairing the triangular fibrocartilage complex arthroscopically. A delay to surgery did not affect clinical outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.