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Lim RQR, Lim LJR, Atzei A, Liu B. Current concepts and new trends in management of isolated triangular fibrocartilage complex injuries. J Hand Surg Eur Vol 2024:17531934241238530. [PMID: 38488619 DOI: 10.1177/17531934241238530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
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.
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Affiliation(s)
- Rebecca Q R Lim
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - Lincoln J R Lim
- Department of Medical Imaging, Western Health, Footscray Hospital, Victoria, Australia
- Department of Surgery, The University of Melbourne, Victoria, Australia
| | - Andrea Atzei
- Pro-Mano, Hand Surgery and Rehabilitation Team, Treviso, Italy - Ospedale San Camillo, Treviso, Italy
| | - Bo Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Capital Medical University, Beijing, China
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2
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Ku S, Zhuang T, Shapiro LM, Richard MJ, Ruch DS, Kamal RN. Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears. J Hand Microsurg 2024; 16:100009. [PMID: 38854387 PMCID: PMC11127526 DOI: 10.1055/s-0042-1757179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability. Methods We created a decision tree to compare the following strategies from a healthcare payer perspective: immediate arthroscopic debridement versus immobilization for 4 or 6 weeks with late debridement as needed. Costs were obtained from the Centers for Medicaid and Medicare Services and a national administrative claims database. Probabilities and health-related quality-of-life measures were obtained from published sources. We conducted sensitivity analyses on model inputs, including a probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations. Results Immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases was both the least costly and most effective strategy. Immediate arthroscopic debridement became cost-effective when success rates of immobilization for 4 or 6 weeks were less than 7.7 or 10.5%, respectively. Our probabilistic sensitivity analysis showed that immobilization for 6 weeks was preferred 97.6% of the time, and immobilization for 4 weeks was preferred 2.4% of the time. Conclusion Although various early and late debridement strategies can be used to treat superficial TFCC tears without DRUJ instability, immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases is the optimal strategy from a cost-effectiveness standpoint.
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Affiliation(s)
- Seul Ku
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Thompson Zhuang
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
| | - Marc J. Richard
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States
| | - David S. Ruch
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, California, United States
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3
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Shojaie B, Bazzi N, Saremi H. A Simple Surgical Technique for Arthroscopic Repair of Traumatic Radial-Side Peripheral TFCC Tear. Tech Hand Up Extrem Surg 2023; 27:200-203. [PMID: 37254705 DOI: 10.1097/bth.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Conventionally, The Triangular Fibrocartilage Complex (TFCC) surgical procedures are complex in nature with open explorations and long hospital stays not to mention the added costs and the psychological stress for both the surgeon and the patient. Nowadays, surgical procedures are looked at in a different scope with the rapid progress of arthroscopic technology and equipment. To elaborate, here we introduce a simple surgical technique for arthroscopic repair of traumatic radial - side peripheral TFCC tear. In spite of the various surgical techniques found in the literature, we just used a k-wire and a couple of needles in order to repair Radial-sided peripheral TFCC tear. the simplicity of the current technique, adequate satisfaction and eliminating the use of a targeting device, is what sets this apart. For emphasis, this technique is less time consuming and is cost-effective with satisfactory result.
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Affiliation(s)
- Babak Shojaie
- Department of Plastic and Reconstructive Surgery, Klinikum Bremen Mitte, Göttingen University of medical Science, Bremen Germany
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nagham Bazzi
- Department of General Surgery, Lebanese University, Lebanon
| | - Hossein Saremi
- Department of Orthopedics, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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4
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Khair Y, Mustafa A, Mestrihi S, Azzam E, Al-Qasaimeh M, Awad D, Ovidiu A. Outcome in TFCC repair using micro anchor and trans‑osseous technique. Exp Ther Med 2023; 26:557. [PMID: 37941586 PMCID: PMC10628646 DOI: 10.3892/etm.2023.12256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/15/2023] [Indexed: 11/10/2023] Open
Abstract
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.
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Affiliation(s)
- Yousef Khair
- Department of Orthopaedics, Royal Medical Services, Zahran, Amman 11183, Jordan
| | - Ayman Mustafa
- Department of Orthopaedics, Royal Medical Services, Zahran, Amman 11183, Jordan
| | - Saab Mestrihi
- Department of Orthopaedics, Royal Medical Services, Zahran, Amman 11183, Jordan
| | - Ehab Azzam
- Department of Orthopaedics, Royal Medical Services, Zahran, Amman 11183, Jordan
| | - Motaz Al-Qasaimeh
- Department of Orthopaedics, Royal Medical Services, Zahran, Amman 11183, Jordan
| | - Dmour Awad
- Department of Orthopaedics, University of Medicine and Pharmacy ‘Grigore T. Popa’, Iasi 700115, Romania
- Orthopaedics Clinic, Clinical Emergency Hospital Sf Spiridon, Iasi 700111, Romania
| | - Alexa Ovidiu
- Department of Orthopaedics, University of Medicine and Pharmacy ‘Grigore T. Popa’, Iasi 700115, Romania
- Orthopaedics Clinic, Clinical Emergency Hospital Sf Spiridon, Iasi 700111, Romania
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5
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Samade R. Imaging relevant to DRUJ and TFCC injuries-a surgeon's perspective. Eur Radiol 2023; 33:6320-6321. [PMID: 37272966 DOI: 10.1007/s00330-023-09775-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Richard Samade
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, The University of Texas Southwestern Medical Center, Dallas, USA.
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6
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Fones L, Cole KP, Kwok M, Gallant GG, Tosti R. All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears. J Hand Surg Am 2023:S0363-5023(23)00252-6. [PMID: 37354193 DOI: 10.1016/j.jhsa.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/25/2023] [Accepted: 05/10/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress. METHODS A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared. RESULTS Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively). CONCLUSIONS All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV; retrospective comparative study.
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Affiliation(s)
- Lilah Fones
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Keegan P Cole
- Philadelphia Hand to Shoulder Center, Philadelphia, PA
| | - Moody Kwok
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Greg G Gallant
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Rick Tosti
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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7
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Silber ZS, Donnelly JC, Farias MJ, Lama CJ, Luther LI, Kosinski LR, Hoy AE, Gil JA. Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review. Clin J Sport Med 2023; 33:270-275. [PMID: 36728770 DOI: 10.1097/jsm.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Zachary S Silber
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Joseph C Donnelly
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Michael J Farias
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Christopher J Lama
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Lauren I Luther
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Lindsay R Kosinski
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Austin E Hoy
- Baylor Scott and White Sports and Orthopedic Center, Waco, Texas
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
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Azócar C, Corvalán G, Cobb P, Román J, Orellana P. Lesiones traumáticas crónicas del complejo fibrocartílago triangular: ¿Cómo enfrentarlas? REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2022. [DOI: 10.1055/s-0042-1758190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
ResumenLas lesiones crónicas del complejo fibrocartílago triangular (CFCT) son una entidad que no ha sido descrita previamente como tal y no existe consenso en su manejo. La temporalidad de la lesión y su potencial de reparación son aspectos fundamentales a la hora de indicar un tratamiento. Proponemos un esquema de enfrentamiento a lesiones traumáticas crónicas del CFCT y describimos una técnica novedosa de reconstrucción con injerto de brachioradialis con asistencia artroscópica. Mostramos los resultados y el seguimiento de dos pacientes intervenidos con esta técnica.
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Affiliation(s)
- Camila Azócar
- Equipo de Mano y Microcirugía, Servicio de Traumatología y Ortopedia, Clínica Indisa, Santiago, Chile
| | - Gonzalo Corvalán
- Equipo de Mano y Microcirugía, Servicio de Traumatología y Ortopedia, Clínica Indisa, Santiago, Chile
| | - Peter Cobb
- Equipo de Mano y Microcirugía, Servicio de Traumatología y Ortopedia, Clínica Indisa, Santiago, Chile
| | - Javier Román
- Equipo de Mano y Microcirugía, Servicio de Traumatología y Ortopedia, Clínica Indisa, Santiago, Chile
| | - Pablo Orellana
- Equipo de Mano y Microcirugía, Servicio de Traumatología y Ortopedia, Clínica Indisa, Santiago, Chile
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9
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Stabilization of the Distal Radioulnar Joint with or without Triangular Fibrocartilage Complex Tear by an External Wrist Band Brace: A Cadaveric Study. Healthcare (Basel) 2022; 10:healthcare10050828. [PMID: 35627965 PMCID: PMC9142000 DOI: 10.3390/healthcare10050828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to investigate whether a watch-shaped external wrist band brace improves distal radioulnar joint (DRUJ) stability. Seven fresh cadaveric arms were used. Using a customized testing system, volar and dorsal translation forces were applied to the radius externally while the ulna was fixed. The test was performed with the forearm in neutral, 60° pronated, and 60° supinated positions, once without the brace and once with the brace applied. In each condition, the amount of translation was measured. Then, the triangular fibrocartilage complex (TFCC) was detached from the ulnar styloid process and the fovea ulnaris, and the same tests were performed again. Detachment of the TFCC significantly increased volar and dorsal translations in all forearm rotations compared to the intact condition (p < 0.05), except for the pronated dorsal translation of the radius (p = 0.091). Brace application significantly reduced volar and dorsal translations in all forearm rotations both in intact specimens and in TFCC-detached specimens (p < 0.05), except for pronated volar and dorsal translations in TFCC-detached specimens (p = 0.101 and p = 0.131, respectively). With the brace applied, the TFCC-detached specimens showed no significant difference in volar or dorsal translation in all forearm rotations compared to the intact specimens (p > 0.05). The external wrist band brace improved DRUJ stability in both normal and TFCC-torn wrists and reduced the DRUJ instability caused by TFCC tear to a near-normal level.
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van der Post A, Jens S, Daams JG, Obdeijn MC, Maas M, Oostra RJ. The Triangular Fibrocartilage Complex In The Human Wrist: A Scoping Review Towards Uniform And Clinically Relevant Terminology. Clin Anat 2022; 35:626-648. [PMID: 35396731 PMCID: PMC9322592 DOI: 10.1002/ca.23880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022]
Abstract
The aim of this scoping review was to assess the composition, terminology, and anatomy of the triangular fibrocartilage complex (TFCC) of the wrist and propose unambiguous terminology regarding the individual components. The review was conducted according to the methodological framework by Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19–32). Electronic databases were searched from inception until September 1, 2021 for original anatomical studies, using MeSH terms and keywords on terminology and anatomy of TFCC components. Studies using gross dissections or macro‐ or microscopic histology were included. Animal studies, fetal studies and studies with unknown disease status, were excluded. A total of 24 studies were included. The articular disc, the radioulnar ligaments, the meniscus homologue and the extensor carpi ulnaris tendon (sub)sheath were unanimously classified as TFCC components. One study did not include the ulnolunate and ulnotriquetral ligaments and only one study did include the ligamentum subcruentum. The largest disagreement existed regarding the inclusion of the ulnar collateral ligament. Terminological ambiguity was seen in “triangular fibrocartilage,” “triangular ligament,” “igamentum subcruentum,” and the “proximal and distal lamina.” Anatomical ambiguity existed especially regarding the radioulnar ligaments, the ulnar attachments of the TFCC and the ulnar collateral ligament. Definitions of the individual TFCC components are redundant, ambiguous, and ill‐defined and therefore subject to different interpretations. In order to preclude confusion, consensus regarding terminology is recommended. We proposed a concise definition of the healthy TFCC that can be used as a starting point for future studies and current clinical practice.
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Affiliation(s)
- A van der Post
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - S Jens
- Rijnstate Arnhem, Department of Radiology and Nuclear Medicine, Arnhem, Netherlands
| | - J G Daams
- Amsterdam UMC, University of Amsterdam, Medical Library, Meibergdreef 9, Amsterdam, Netherlands
| | - M C Obdeijn
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, Meibergdreef 9, Amsterdam, Netherlands
| | - M Maas
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - R J Oostra
- Amsterdam UMC, University of Amsterdam, Department of Medical Biology, Section Clinical Anatomy and Embryology, Meibergdreef 9, Amsterdam, Netherlands
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11
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Hearon BF, Frantz LM, Helsper EA, Morris HA. Experience with Diagnosis and Management of Distal Radioulnar Joint Instability. J Wrist Surg 2021; 10:392-400. [PMID: 34631291 PMCID: PMC8489992 DOI: 10.1055/s-0041-1726408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Bernard F. Hearon
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas
- Advanced Orthopaedic Associates, Wichita, Kansas
| | - Lisa M. Frantz
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas
| | - Elizabeth A. Helsper
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas
| | - Harry A. Morris
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas
- Advanced Orthopaedic Associates, Wichita, Kansas
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12
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Xiao JY, Liu B, Li L, Shi HF, Wu F. Predictors for poor outcome for conservatively treated traumatic triangular fibrocartilage complex tears. Bone Joint J 2021; 103-B:1386-1391. [PMID: 34334041 DOI: 10.1302/0301-620x.103b8.bjj-2020-2310.r2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. METHODS This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome. RESULTS In total, 76% of wrists (42/55) treated with an above-elbow splint had a good outcome, compared to only 29% (10/34) with a short-arm splint (p < 0.001). The presence of a complete foveal TFCC tear (p = 0.009) and a dorsally subluxated distal radioulnar joint (DRUJ) (p = 0.032) were significantly associated with a poor outcome on univariate analysis. Sex, age, energy of injury, hand dominance, manual occupation, ulnar variance, and a delay in initial treatment demonstrated no significant association. Multiple logistic regression revealed that short-arm immobilization (p < 0.001) and DRUJ subluxation (p = 0.020) were significant independent predictive factors of an eventual poor outcome. CONCLUSION Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. Early surgery should be considered for patients with dorsal ulnar subluxation treated with short-arm splints to prevent prolonged morbidity. Cite this article: Bone Joint J 2021;103-B(8):1386-1391.
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Affiliation(s)
- Ji-Yang Xiao
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, The Fourth Clinical College of Peking University, Beijing, China
| | - Bo Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, The Fourth Clinical College of Peking University, Beijing, China
| | - Lily Li
- Addenbrooke's Hospital, Cambridge, UK
| | - Hai-Fei Shi
- Department of Orthopaedics, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Feiran Wu
- Department of Orthopaedics, University Hospitals Birmingham, Birmingham, UK
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13
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Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair. J Am Acad Orthop Surg 2021; 29:518-525. [PMID: 34078841 DOI: 10.5435/jaaos-d-20-00998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/25/2021] [Indexed: 02/01/2023] Open
Abstract
Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.
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Editorial Commentary: The Hook Test Is More Accurate for Detecting Foveal Triangular Fibrocartilage Complex Tears but Not More Important Than the Trampoline Test. Arthroscopy 2021; 37:1808-1810. [PMID: 34090566 DOI: 10.1016/j.arthro.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
Wrist arthroscopy is a successful tool to diagnose and treat several intra-articular wrist pathologies. To assess the stability and integrity of the triangular fibrocartilage complex (TFCC), the most commonly injured structure in the ulnocarpal compartment, the trampoline and hook tests are frequently used in daily practice. However, their arthroscopic performance measures have not been well elucidated to date. While the hook test may primarily be seen as a sensitive tool to detect foveal TFCC tears, the trampoline test is of equal importance for the clinician because it can detect frequently occurring superficial (distal) tears in the peripheral TFCC area. As opposed to the hook test, however, the trampoline test might more easily lead to interrater disagreement since the rebound after probing is rather a continuum than a binary measure and might be related to a different severity of peripheral TFCC disruption. The combination of both tests should thus be pursued since they complement each other very well. Proper interpretation of the tests needs sufficient experience and should be done in concordance with the clinical evaluation (ie, fovea sign, distal radioulnar joint ballottement test). Hence, the hook test may be more accurate to detect foveal TFCC tears but all together not more important than the trampoline test to establish the correct diagnosis. For once, Captain Hook has won!
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Liu EH, Suen K, Tham SK, Ek ET. Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review. J Wrist Surg 2021; 10:70-83. [PMID: 33552699 PMCID: PMC7850810 DOI: 10.1055/s-0040-1718913] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Edward H. Liu
- Department of Orthopaedic Surgery, Division of Hand Surgery, Monash University, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Kary Suen
- Department of Orthopaedic Surgery, Division of Hand Surgery, Monash University, Dandenong Hospital, Melbourne, Victoria, Australia
| | - Stephen K. Tham
- Department of Orthopaedic Surgery, Division of Hand Surgery, Monash University, Dandenong Hospital, Melbourne, Victoria, Australia
- Victorian Hand Surgery Associates, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Monash Medical Centre, Melbourne, Victoria, Australia
- Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute/St. Vincent's Institute Fitzroy, Melbourne, Victoria, Australia
| | - Eugene T. Ek
- Department of Orthopaedic Surgery, Division of Hand Surgery, Monash University, Dandenong Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Monash Medical Centre, Melbourne, Victoria, Australia
- Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute/St. Vincent's Institute Fitzroy, Melbourne, Victoria, Australia
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia
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Jain DKA, Wahegaonkar AL. Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC! Indian J Orthop 2021; 55:310-317. [PMID: 33927808 PMCID: PMC8046677 DOI: 10.1007/s43465-020-00319-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/20/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine. PURPOSE Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint. CONCLUSION Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.
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Affiliation(s)
- Darshan Kumar A. Jain
- Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bangalore, Karnataka 560055 India
| | - Abhijeet L. Wahegaonkar
- Division of Hand and Microvascular Services, Sancheti Hospital, Pune, Maharashtra 411005 India
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van der Post AS, Jens S, Smithuis FF, Obdeijn MC, Oostra RJ, Maas M. The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology. Skeletal Radiol 2021; 50:2195-2204. [PMID: 33864484 PMCID: PMC8449761 DOI: 10.1007/s00256-021-03779-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study is to provide a reference for morphology, homogeneity, and signal intensity of triangular fibrocartilage complex (TFCC) and TFCC-related MRI features in adolescents. MATERIALS AND METHODS Prospectively collected data on asymptomatic participants aged 12-18 years, between June 2015 and November 2017, were retrospectively analyzed. A radiograph was performed in all participants to determine skeletal age and ulnar variance. A 3-T MRI followed to assess TFCC components and TFCC-related features. A standardized scoring form, based on MRI definitions used in literature on adults, was used for individual assessment of all participants by four observers. Results per item were expressed as frequencies (percentages) of observations by all observers for all participants combined (n = 92). Inter-observer agreement was determined by the unweighted Fleiss' kappa with 95% confidence intervals (95% CI). RESULTS The cohort consisted of 23 asymptomatic adolescents (12 girls and 11 boys). Median age was 13.5 years (range 12.0-17.0). Median ulnar variance was -0.7 mm (range - 2.7-1.4). Median triangular fibrocartilage (TFC) thickness was 1.4 mm (range 0.1-2.9). Diffuse increased TFC signal intensity not reaching the articular surface was observed in 30 (33%) observations and a vertical linear increased signal intensity with TFC discontinuation in 19 (20%) observations. Discontinuation between the volar radioulnar ligament and the TFC in the sagittal plane was seen in 23 (25%) observations. The extensor carpi ulnaris was completely dislocated in 10 (11%) observations, more frequent in supinated wrists (p = 0.031). Inter-observer agreement ranged from poor to fair for scoring items on the individual TFCC components. CONCLUSION MRI findings, whether normal variation or asymptomatic abnormality, can be observed in TFCC and TFCC-related features of asymptomatic adolescents. The rather low inter-observer agreement underscores the challenges in interpreting these small structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy.
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Affiliation(s)
- Anne-Sophie van der Post
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
| | - Sjoerd Jens
- grid.415930.aDepartment of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Frank F. Smithuis
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Miryam C. Obdeijn
- grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,grid.7177.60000000084992262Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- grid.7177.60000000084992262Department of Medical Biology, Section Clinical Anatomy and Embryology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
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Kwon BC, Lee JH, Lee SY. What Is the Effect of the Ulnar-Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar-Side Triangular Fibrocartilage Complex Tear? Arthroscopy 2020; 36:2415-2422. [PMID: 32442714 DOI: 10.1016/j.arthro.2020.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the outcomes of arthroscopic repair of peripheral ulnar-side triangular fibrocartilage complex (TFCC) tears between patients with and without ulnar-plus variance (UPV) and to identify factors associated with index surgery failure in these patients. METHODS We retrospectively analyzed 50 consecutive patients who underwent arthroscopic repair of peripheral ulnar-side TFCC tears from June 2014 to February 2018. We selected patients who were aged at least 18 years and underwent arthroscopic repair of peripheral ulnar-side TFCC tears. We excluded those with a fractured or dislocated wrist, ulnar impaction syndrome, degenerative or inflammatory arthritis of the wrist, or neurologic conditions that affect upper-extremity function, as well as those who received less than 12 months' follow-up. We evaluated the patients with a visual analog scale for pain in 3 domains (overall, with hard work, and at rest), the Patient-rated Wrist Evaluation, range of motion, and grip strength. Clinical outcomes and arthroscopic findings were compared between patients with and without UPV (UPV group and non-UPV group, respectively). We calculated the relative risk and 95% confidence interval for younger age (<30 years), sex, UPV, and coexisting degenerative central TFCC tear (type 2 tear) to determine the risk factors for arthroscopic repair failure. RESULTS No significant differences were noted between the 2 groups regarding visual analog scale pain and Patient-rated Wrist Evaluation scores and rates of excellent or improved outcomes (P > .05). Arthroscopic repair failure was found in 4 patients. A coexisting type 2 TFCC tear was the only significant risk factor (relative risk, 49.5; 95% confidence interval, 2.94-83.96; P = .007) for arthroscopic repair failure. CONCLUSIONS UPV did not significantly affect the outcomes of arthroscopic repair of peripheral ulnar-side TFCC tears. However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients. LEVEL OF EVIDENCE Level IV, prognostic study.
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Affiliation(s)
- Bong Cheol Kwon
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.
| | - Jeong Hwan Lee
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Suk Yoon Lee
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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CORR Insights®: What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability? Clin Orthop Relat Res 2019; 477:450-451. [PMID: 30624317 PMCID: PMC6370100 DOI: 10.1097/corr.0000000000000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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