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Feitz R, Kooij YEV, Oest MJWVD, Souer JS, Hovius SER, Selles RW. Patient-Rated Wrist Evaluation Threshold for Successful Open Surgery of the Triangular Fibrocartilage Complex. J Wrist Surg 2024; 13:302-309. [PMID: 39027032 PMCID: PMC11254475 DOI: 10.1055/s-0043-1771010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/07/2023] [Indexed: 07/20/2024]
Abstract
Purpose To determine thresholds in patient-reported outcome measures at baseline in patients electing to undergo triangular fibrocartilage complex (TFCC) surgery to select patients with clinically improved outcomes. Methods The study cohort comprised consecutive patients who underwent open TFCC repair between December 2011 and December 2018 in various clinics in the Netherlands. All patients were asked to complete the patient-rated wrist evaluation (PRWE) questionnaire at baseline as well as at 12 months postoperatively. The minimal clinically important difference (MCID) for the PRWE was calculated to be 24 using an anchor-based method. We compared patient, disease, and surgical characteristics between patients who did and did not reach the MCID. The t -tests and chi-square tests were undertaken to test differences between outcomes and satisfaction in patients who did or did not reach the MCID. Results Patients (34%) who did not reach MCID had a longer history of complaints. The chances of reaching the MCID for patients with a low PRWE score at baseline were slim. Of patients with a PRWE score <34 at baseline, only 14% reached the MCID, whereas in patients with a PRWE score of ≥34, 69% reached the MCID. Conclusion A PRWE total score at baseline <34 is a strong signal to reconsider open surgery of the TFCC because the chance of reaching a clinically meaningful outcome is slim. Level of Evidence II. Type of Study Therapeutic.
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Affiliation(s)
- Reinier Feitz
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Yara E. van Kooij
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, The Netherlands
- Xpert Clinics, Xpert Handtherapie, Flight Forum, Eindhoven, The Netherlands
| | - Mark J. W. van der Oest
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus MC, Rotterdam, The Netherlands
- Hand and Wrist Center, Xpert Clinics, Amsterdam, The Netherlands
| | | | - Steven E. R. Hovius
- Hand and Wrist Center, Xpert Clinics, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ruud W. Selles
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, The Netherlands
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Lee SW, Hong JJ, Sung SY, Park TH, Kim JS. Clinical Outcomes and Failure Rate of Triangular Fibrocartilage Complex Foveal Repair Were Comparable between Arthroscopic and Open Techniques. J Clin Med 2024; 13:2766. [PMID: 38792310 PMCID: PMC11122638 DOI: 10.3390/jcm13102766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
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.
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Affiliation(s)
- Shin Woo Lee
- Department of Orthopaedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul 07804, Republic of Korea;
| | - Jung Jun Hong
- Department of Orthopaedic Surgery, Yonsei Wa Hospital, Incheon 21557, Republic of Korea;
| | - Seung-Yong Sung
- Department of Orthopaedic Surgery, College of Medicine, Catholic-Kwandong University, Incheon 22711, Republic of Korea;
| | - Tae-Hoon Park
- Department of Orthopaedic Surgery, Gangnam Nanoori Hospital, Seoul 06048, Republic of Korea;
| | - Ji-Sup Kim
- Department of Orthopaedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul 07804, Republic of Korea;
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Lo IN, Chen KJ, Yin CY, Huang HK, Wang JP, Huang YC. Comparing the Outcomes of Suture Anchor Repair and Rein-Type Capsular Suture for Triangular Fibrocartilage Complex Foveal Tears With a Minimum 2-Year Follow-Up. J Hand Surg Am 2024; 49:321-328. [PMID: 38300191 DOI: 10.1016/j.jhsa.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Recent biomechanical studies have highlighted the importance of foveal reinsertion when repairing triangular fibrocartilage complex (TFCC) injury with foveal tears. However, clinical studies comparing different repair techniques are scarce. We compared the clinical outcomes of suture anchor repair and rein-type capsular suture in patients with TFCC palmer 1B foveal tears with a minimum of 2-year follow-up. METHODS This was a single-surgeon, single-center, retrospective, comparative study. We included patients who underwent TFCC repair surgery due to a foveal tear from December 2013 to October 2018 with a minimum follow-up of 24 months. Postoperative Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, Modified Mayo Wrist Score, visual analogue scale for pain, wrist range of motion, and grip strength were compared. We also measured the maximal ulnar head displacement with dynamic ultrasound to quantify distal radioulnar joint stability. RESULTS In total, 103 patients were in the suture anchor group (group A) and 84 patients in the rein-type capsular suture group (group B). The mean follow-up time exceeded three years for both groups. There was a minimal difference regarding QuickDASH score, visual analogue scale for pain, and grip strength ratio between the two groups. The rein-type group had significantly better Modified Mayo Wrist Score. The suture anchor group showed better distal radioulnar joint stability with dynamic ultrasound, but was more limited in ulnar deviation. However, these differences are most likely clinically insignificant. CONCLUSIONS Both suture anchor repair and rein-type capsular suture yielded satisfactory results for TFCC 1B foveal tear in a minimum of 2-year follow-up. The functional scores were similar, and no major complications or recurrent instability were noted in either group. TYPE OF STUDY/LEVEL OF EVIDENCE Retrospective Therapeutic Comparative Investigation IV.
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Affiliation(s)
- I-Ning Lo
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Jung Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopaedics, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Cheng-Yu Yin
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hui-Kuang Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Orthopaedics, Chiayi Christian Hospital, Chiayi, Taiwan; Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Jung-Pan Wang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Choudhury MM, Yap RTJ, Jiang JKH, Chia DSY, Chin AYH. An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple. Tech Hand Up Extrem Surg 2024; 28:19-25. [PMID: 38380473 DOI: 10.1097/bth.0000000000000454] [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: 02/22/2024]
Abstract
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.
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Affiliation(s)
- Muntasir Mannan Choudhury
- Department of Orthopaedic Surgery, Sengkang General Hospital
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital
- SingHealth Duke-NUS Musculoskeletal Sciences ACP, Singapore
| | - Robert Tze Jin Yap
- Department of Orthopaedic Surgery, Sengkang General Hospital
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital
- SingHealth Duke-NUS Musculoskeletal Sciences ACP, Singapore
| | - Jackson Kian Hong Jiang
- Department of Orthopaedic Surgery, Sengkang General Hospital
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital
- SingHealth Duke-NUS Musculoskeletal Sciences ACP, Singapore
| | - Dawn Sinn Yii Chia
- Department of Orthopaedic Surgery, Sengkang General Hospital
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital
- SingHealth Duke-NUS Musculoskeletal Sciences ACP, Singapore
| | - Andrew Yuan Hui Chin
- Department of Orthopaedic Surgery, Sengkang General Hospital
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital
- SingHealth Duke-NUS Musculoskeletal Sciences ACP, Singapore
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Shaer SA, van der Palen J, Teunissen J, Fink A, van der Heijden B, Zöphel O. An alternative treatment for degenerative triangular fibrocartilage complex injuries with distal radioulnar joint instability: first experience with 48 patients. J Hand Surg Eur Vol 2024; 49:240-249. [PMID: 37694851 PMCID: PMC10845826 DOI: 10.1177/17531934231197942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 07/20/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
Treatment of ulnar impaction syndrome combined with distal radioulnar joint instability due to irreparable degenerative triangular fibrocartilage complex injuries can be complex. We describe the outcomes of a novel technique for restoring distal radioulnar stability due to ulnar impaction syndrome using a distally based extensor carpi ulnaris tendon strip combined with ulnar shortening osteotomy in 48 patients. Patients were assessed using standardized outcome measurements. The patient-rated wrist/hand evaluation total score improved from 66 (SD 15) at intake to 40 (SD 25) at 3 months, and 28 (SD 23) at 12 months postoperatively (p < 0.001). Wrist extension and flexion improved significantly at 12 months from 53° (SD 11) to 65° (SD 8) (p < 0.001) and from 45° (SD 10) to 56° (SD 12) (p = 0.01), respectively. Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. Level of evidence: IV.
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Affiliation(s)
- Sanharib Al Shaer
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
- Hand and Wrist Center, Xpert Clinics, Handtherapy, Enschede, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, Enschede & Section Cognition, Data and Education, Faculty BMS, University of Twente, Enschede, The Netherlands
| | - Joris Teunissen
- Hand and Wrist Center, Xpert Clinics, Handtherapy, Enschede, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Alexandra Fink
- Hand and Wrist Center, Xpert Clinics, Handtherapy, Enschede, The Netherlands
| | - Brigitte van der Heijden
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Jeroen Bosch Ziekenhuis ‘s-Hertogenbosch, The Netherlands
| | - Oliver Zöphel
- Hand and Wrist Center, Xpert Clinics, Handtherapy, Enschede, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Ziekenhuisgroep Twente, Hengelo, The Netherlands
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Ma HH, Wang JP, Yang CY. Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review. J Orthop Surg Res 2024; 19:72. [PMID: 38229172 PMCID: PMC10790567 DOI: 10.1186/s13018-024-04530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
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.
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Affiliation(s)
- Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Orthopaedics, Department of Surgery, Taipei Veterans General Hospital Taitung Branch, Taitung, Taiwan
- Department of Surgery, Taipei Veterans General Hospital Yuli Branch, Hualien, Taiwan
| | - Jung-Pan Wang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chen-Yuan Yang
- Department of Orthopedic Surgery, Kuang Tien General Hospital, No. 117, Shatian Rd., Shalu Dist., Taichung City, 433, Taiwan.
- Department of Nursing, Hungkuang University, No. 1018, Sec. 6, Taiwan Blvd., Shalu Dist., Taichung City, 433, Taiwan.
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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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Marès O, Bosch C. Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions. Orthop Traumatol Surg Res 2023; 109:103465. [PMID: 36942792 DOI: 10.1016/j.otsr.2022.103465] [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: 01/24/2022] [Accepted: 07/01/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Olivier Marès
- CHU de Nîmes, avenue du Professor Debré, 30000 Nîmes, France.
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Gvozdenovic R, Hessler Simonsen S. A modified arthroscopic ulnar tunnel technique for foveal triangular fibrocartilage complex injury. J Plast Surg Hand Surg 2023; 57:308-314. [PMID: 35533690 DOI: 10.1080/2000656x.2022.2070179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Robert Gvozdenovic
- Department of Hand Surgery, Herlev/Gentofte University Hospital of Copenhagen, Hellerup, Denmark.,Faculty of Health and Medical Sciences, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sabine Hessler Simonsen
- Department of Hand Surgery, Herlev/Gentofte University Hospital of Copenhagen, Hellerup, Denmark
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10
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Fontana M, Rotini M, Battiston B, Artiaco S, Dutto E, Sard A, Colozza A, Vicenti G, Cavallo M, Rotini R. UNSTABLE LESIONS OF THE FOREARM: TERMINOLOGY, EVALUATIVE SCORE AND SYNOPTIC TABLE. Injury 2022; 54 Suppl 1:S85-S95. [PMID: 37032570 DOI: 10.1016/j.injury.2022.09.047] [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: 06/03/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 04/11/2023]
Abstract
The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.
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Affiliation(s)
| | | | | | | | | | | | | | - Giovanni Vicenti
- School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic & Trauma Unit, Bari, Italy.
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11
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Afifi A, Abdel-Ati EA, Abdel-Wahed M, Moharram AN. Arthroscopic-Assisted Foveal Reattachment of Triangular Fibrocartilage Complex Tears With Distal Radioulnar Joint Instability: A Comparison of Suture Anchors and Transosseous Sutures. J Hand Surg Am 2022; 47:507-516. [PMID: 35341629 DOI: 10.1016/j.jhsa.2022.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/30/2021] [Accepted: 01/21/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical outcomes of arthroscopically-assisted suture anchor repair and transosseous sutures for repair of foveal triangular fibrocartilage complex tears in patients with distal radioulnar joint (DRUJ) instability. METHODS Sixty patients with triangular fibrocartilage complex foveal detachment associated with DRUJ instability were prospectively recruited and randomized into 2 equal groups-the anchor repair group and the transosseous repair group. The primary outcome was DRUJ function after 2 years, which was assessed by the DRUJ evaluating system. The secondary outcomes were grip strength, visual analog scale for pain, Mayo Modified Wrist ScorePatient-Rated Wrist Evaluation score, and the Disabilities of the Arm, Shoulder, and Hand score. RESULTS There were no significant differences between the groups for any of the outcome measures. Good-to-excellent outcomes (according to the DRUJ evaluation system) were achieved in 27 (90%) patients in the anchor repair group and 26 (86.7%) patients in the transosseous repair group. Fewer complications were observed in the anchor repair group. CONCLUSIONS Both techniques yielded good and comparable outcomes with a lesser incidence of early complications in the anchor repair group. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Ahmed Afifi
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Emad A Abdel-Ati
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abdel-Wahed
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ashraf N Moharram
- Hand and Microsurgery Unit, Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
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Yeh CW, Hsu CE, Ho TY, Wei BH, Wang WC, Chiu YC. Midterm Results of Arthroscopy-Assisted "Tent Form" Triangular Fibrocartilage Complex Repair With Dorsal Distal Radioulnar Joint Capsule Imbrication for Posttraumatic Chronic Distal Radioulnar Joint Instability. Arthroscopy 2022; 38:1846-1856. [PMID: 35042008 DOI: 10.1016/j.arthro.2022.01.009] [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: 08/11/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of "tent form" triangular fibrocartilage complex (TFCC) repair combined with dorsal distal radioulnar joint (DRUJ) capsule imbrication for posttraumatic chronic DRUJ instability. METHODS All patients treated with arthroscopic "tent form" TFCC repair and DRUJ capsule imbrication from 2016 to 2019 were retrospectively reviewed. The inclusion criteria were symptomatic chronic DRUJ instability for >6 months and dorsal DRUJ subluxation on magnetic resonance imaging. The Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, grip strength, Modified Mayo Wrist Score, range of motion, and distal radioulnar joint stability were assessed for a minimum of 2 years postoperatively. RESULTS Thirty-eight patients were included in the final analysis. The average follow-up duration was 35.6 months (range, 24-48 months). The 24-month postoperative grip strengths and 3-dimensional motions of wrist were not significantly different from that of the nonoperated wrist. Compared with their preoperative status, Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, and Modified Mayo Wrist Score indicated the significant improvement with P values of .001, .001, and .002, respectively. CONCLUSIONS In chronic DRUJ instability with a loosening dorsal capsule, "tent form" TFCC transcapsular repair combined with DRUJ capsule imbrication restored the integrity of TFCC and dorsal DRUJ capsule and achieved a promising outcome. We recommend this procedure as an option of treatment for patients with posttraumatic chronic DRUJ instability. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Chen-Wei Yeh
- School of Medicine, China Medical University, Taichung, Taiwan; Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-En Hsu
- Sports Recreation and Health Management Degree Program, Tunghai University, Taichung, Taiwan; Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsung-Yu Ho
- School of Medicine, China Medical University, Taichung, Taiwan; Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Bor-Han Wei
- Department of Orthopedics, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Wei-Chih Wang
- School of Medicine, China Medical University, Taichung, Taiwan; Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yung-Cheng Chiu
- School of Medicine, China Medical University, Taichung, Taiwan; Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.
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13
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Yu A, Zhao X, Zhao H, Luo J, Yin H, Xu W. Load-Bearing Radioulnar Distances to Evaluate an Unstable Distal Radioulnar Joint in Patients With Triangular Fibrocartilage Complex Tears. J Hand Surg Am 2022; 47:437-443. [PMID: 35248425 DOI: 10.1016/j.jhsa.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 11/14/2021] [Accepted: 01/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Tears of the proximal component of the triangular fibrocartilage complex (pc-TFCC) lead to instability in the distal radioulnar joint. The aim of this study was to measure the load-bearing radioulnar distances (RaUls) and to evaluate its diagnostic suitability in patients with pc-TFCC tears. METHODS We retrospectively assessed and compared the lateral wrist radiographs of 61 adult patients with arthroscopically confirmed tears of pc-TFCC with those of a control group of 64 healthy participants. The RaUl was measured on lateral radiographs, and the difference in RaUl (D-value) between load-bearing and nonloading conditions was calculated in the 2 groups. Receiver operator characteristic curves were plotted to determine the diagnostic accuracy and optimal cutoff-score of load-bearing RaUl and RaUl D-value. The diagnostic performance was verified in a validation sample of patients (30 wrists) with pc-TFCC tears and a control group of healthy individuals (30 wrists). RESULTS In the training sample, load-bearing RaUls of the affected wrists were higher than the same side of the controls (12.0 mm vs 7.1 mm). The TFCC-injury group showed a significantly higher RaUl D-value than the control group (8.5 mm vs 3.4 mm). Using a receiver operator characteristic curve, the cutoff value of load-bearing RaUl was 10 mm (sensitivity = 97.6%, specificity = 85.7%) and that of RaUl D-value was 6.5 mm (sensitivity = 90.2%, specificity = 78.5%). The areas under the curve of load-bearing RaUl and RaUl D-value were 0.96 and 0.88, respectively. In the test sample, the sensitivity, specificity, and accuracy of RaUl were 0.93, 0.70, and 0.82 and those of RaUl D-value were 0.77, 0.83, and 0.80 respectively. CONCLUSIONS Load-bearing RaUl measurement is a simple method to diagnose an unstable distal radioulnar joint in patients with TFCC injury. The load bearing RaUl of >10 mm or RaUl D-value of >6.5 mm can be used to differentiate TFCC injuries and showed acceptable accuracy. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Aiping Yu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
| | - Xuanyu Zhao
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
| | - Huali Zhao
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China; NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China; Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Huawei Yin
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Wendong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
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14
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Yang CY, Chen WJ. Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex. J Hand Surg Eur Vol 2022; 47:486-494. [PMID: 35001678 DOI: 10.1177/17531934211065874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Foveal disruption of the triangular fibrocartilage complex contributes to the instability of distal radioulnar joint. We have developed an arthroscopic transosseous foveal footprint repair technique, which maximizes the contact between the disrupted triangular fibrocartilage complex and its foveal footprint for better healing by using four sutures in a divergent configuration through a 1.6-mm bone tunnel. Twelve patients with triangular fibrocartilage complex foveal injuries who had undergone this repair technique were reviewed with a mean follow-up of 53 months. All patients achieved significant improvement in the modified Mayo wrist score and the Disabilities of the Arm, Shoulder and Hand score. All patients had stable distal radioulnar joints with comparable ranges of motion and grip strengths between the operated and contralateral wrists. There was no significant difference in functional score in those who were treated more than 6 months after injury.Level of evidence: IV.
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Affiliation(s)
- Chen-Yuan Yang
- Division of Hand and Reconstructive Microsurgery, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Wei-Jen Chen
- Department of Orthopedics, Show Chwan Memorial Hospital, Changhua, Taiwan.,Department of Orthopedics, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
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15
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Lee KH, Shim BJ, Gong HS. Open Foveal Repair of the Triangular Fibrocartilage Complex Tears Associated with Symptomatic Ulnar Styloid Non-union. J Hand Surg Asian Pac Vol 2022; 27:248-255. [PMID: 35404212 DOI: 10.1142/s2424835522500321] [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: 11/18/2022]
Abstract
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).
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Affiliation(s)
- Kyoung Hwan Lee
- Contributed equally and therefore share first authorship.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bum Jin Shim
- Contributed equally and therefore share first authorship.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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16
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Yao W, Li Y, Liu Z, Yao L, Liang R, Wu J, Yuan L. Autologous Oxygen-Releasing Nano-Biomimetic Scaffold with Chondrocytes Promotes Joint Repair After Trauma. J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.2930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Our study assesses the role of a scaffold constructed by co-culture of autologous oxygen-releasing biomimetic scaffold (AONS) and chondrocytes in joint repair after trauma. A composite scaffold structure was used and a scaffold constructed of AONS and chondrocytes was transplanted into
SD rats to create models of patellar cartilage fracture and hip osteochondral fracture, respectively followed by analysis of cell proliferation by immunofluorescence method, osteogenesis-related gene expression by RT-PCR, chondrocytes apoptosis by TUNEL staining. The blank control group and
AONS composite chondrocytes have significant differences in apoptosis and cell proliferation of two fracture types (P <0.05). The autologous oxygen-releasing nanometers at 4 and 8 weeks showed a significant difference in the number of PCNA and TUNEL cells between biomimetic scaffold
and chondrocytes in two groups (P < 0.05). The AONS and chondrocytes were effective for two types of fractures at 1, 4 and 8 weeks. The expression of various markers of intrachondral osteogenesis was decreased and the markers of hip osteochondral fracture were increased significantly
(P < 0.05). Joint recovery was better than patellar cartilage fractures. The AONS composite chondrocyte scaffold promotes repair of patellar cartilage fractures and hip osteochondral fractures with a better effect on hip osteochondral fractures.
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Affiliation(s)
- Wuping Yao
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Yuji Li
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Zhi Liu
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Liuyi Yao
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Rui Liang
- Gansu Maternal and Child Health Hospital, Lanzhou, 730000, Gansu, China
| | - Jinqiu Wu
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Lingwei Yuan
- Department of Orthopedics, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, China
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17
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Zhang W, Hou P, Wang C, Wu T, Ho PC, Sun L. Arthroscopic one-tunnel transosseous reconstruction of chronic triangular fibrocartilage complex foveal tears: outcomes in 12 patients. J Hand Surg Eur Vol 2022; 47:296-301. [PMID: 34763553 DOI: 10.1177/17531934211056854] [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: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Wen Zhang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Peng Hou
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chunyang Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tianyi Wu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Pak-Cheong Ho
- Department of Orthopaedic and Traumatology, Prince of Wales Hospital, Hong Kong, China *Wen Zhang and Peng Hou contributed equally to this work
| | - Luyuan Sun
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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18
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McCarron L, Bindra R, Coombes BK, Bisset L. Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review. J Hand Ther 2021; 36:179-195. [PMID: 34972604 DOI: 10.1016/j.jht.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/08/2021] [Accepted: 10/02/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Luke McCarron
- School of Medicine and Dentistry, Griffith University, Queensland, Australia; Occupational Therapy Department, Bond University, Queensland, Australia; Orthopaedic and Trauma Department, Gold Coast Hospital and Health Service, Queensland, Australia.
| | - Randy Bindra
- School of Medicine, Griffith University, Queensland, Australia; Orthopaedic and Trauma Department, Gold Coast Hospital and Health Service, Queensland, Australia
| | - Brooke K Coombes
- School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Leanne Bisset
- School of Medicine and Dentistry, Griffith University, Queensland, Australia
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19
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Concurrent musculoskeletal complaints in elbows, shoulders, and necks after common hand and forearm injuries or conditions: A cross-sectional study among 600 patients. J Hand Ther 2021; 34:543-548. [PMID: 32893097 DOI: 10.1016/j.jht.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/03/2020] [Accepted: 05/02/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a cross-sectional study among 600 patients. INTRODUCTION Isolated hand and forearm injuries or conditions are common in the emergency and orthopedic departments. So far, little is known about whether these patients suffer from concurrent musculoskeletal complaints (MSCs) besides their hand and forearm complaints. Neglecting concurrent MSCs in the upper limbs and necks could hamper rehabilitation and prolong the time taken to return to daily and work-related activities. PURPOSE OF THE STUDY The purpose of this study was to investigate the prevalence of concurrent MSCs in the elbow, shoulder, and neck after common hand and/or forearm injuries or conditions. METHODS This study included 600 patients with any type of diagnosis referred to rehabilitation after hand and/or forearm injuries or conditions. Basic characteristics, diagnoses, and location of patients' symptoms were collected and analyzed. RESULTS The overall prevalence of concurrent MSCs was 40%. Twenty-eight percent of the whole sample developed concurrent MSCs after the hand and forearm injury or condition. The gender distribution was 68% women and 32% men. The most common location for complaints was the shoulder (62%), followed by the elbow (49%), and the neck (32%). DISCUSSION The present results suggest that MSCs from the elbows, shoulders, or necks are very common in patients with hand and/or forearm injuries or conditions. CONCLUSION Clinicians treating patients with isolated hand and forearm injuries or conditions should be aware of the high prevalence of concurrent MSCs. Future research should investigate if specific rehabilitation, focusing on concurrent MSCs, may influence the outcome in this population.
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20
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Kim BS, Jung KJ, Nho JH, Kim HK, Kim G. Morphologic Characteristics of the Sigmoid Notch of the Distal Radius for Patients With Peripheral Triangular Fibrocartilage Complex Tear. Orthopedics 2021; 44:e729-e734. [PMID: 34618642 DOI: 10.3928/01477447-20211001-13] [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] [Indexed: 02/03/2023]
Abstract
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.].
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21
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Feitz R, Khoshnaw S, van der Oest MJW, Souer JS, Slijper HP, Hovius SER, Selles RW. Long-term patient-reported outcomes for open surgery of the triangular fibrocartilage complex. Bone Jt Open 2021; 2:981-987. [PMID: 34818898 PMCID: PMC8636291 DOI: 10.1302/2633-1462.211.bjo-2021-0140.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aims Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC. Methods A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function. Results A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low. Conclusion Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC. Cite this article: Bone Jt Open 2021;2(11):981–987.
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Affiliation(s)
- Reinier Feitz
- Hand Surgery, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Sara Khoshnaw
- Hand Surgery, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Mark J W van der Oest
- Hand Surgery, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center, Rotterdam, Netherlands.,Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Harm P Slijper
- Hand Surgery, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Steven E R Hovius
- Hand Surgery, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Ruud W Selles
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center, Rotterdam, Netherlands.,Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, Netherlands
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22
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Lu C, Zhang H, Zhang L, Wang P, Wang X. [Anatomical repair of Atzei-EWAS type 2 triangular fibrocartilage complex injury under wrist arthroscopy]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1417-1421. [PMID: 34779167 DOI: 10.7507/1002-1892.202104126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the effectiveness of anatomical repair of Atzei-EWAS type 2 triangular fibrocartilage complex (TFCC) injury under wrist arthroscopy. Methods Between March 2018 and March 2020, 16 patients with Atzei-EWAS type 2 TFCC injury were admitted, and the TFCCs were anatomically repaired with a three-dimensional suture with a thread anchor under wrist arthroscopy. There were 10 males and 6 females with an average of 40.2 years (range, 22-54 years). The disease duration ranged from 2 to 9 months (mean, 6.4 months). Preoperative grip strength of the affected limb was (20.06±3.38) kg, wrist range of motion in flexion and extension was (117.19±7.74)°, radial-ulnar deviation was (31.25±5.32)°, forearm rotation range of motion was (137.19±14.83)°, visual analogue scale (VAS) score was 5.6±1.2. At last follow-up, the effectiveness was evaluated by the grip strength of the affected limb, the range of motion of the wrist joint, the VAS score, and the modified Mayo wrist score. Results All incisions healed by first intention. One case had paralysis of the dorsal branch of the ulnar nerve after operation, and no other complications occurred in other cases. All patients were followed up 12-18 months (mean, 14.5 months). The distal radioulnar joint stability of all patients recovered. At last follow-up, the grip strength of the affected limb was (24.88±3.26) kg, the range of motion in flexion and extension was (146.59±6.49)°, radial-ulnar deviation was (39.38±6.55)°, and forearm rotation range of motion was (152.50±11.55)°, which were significantly higher than those before operation ( P<0.05); the VAS score was 0.9±0.8, which was significantly lower than that before operation ( t=21.029, P=0.000). The modified Mayo wrist score was rated as excellent in 10 cases, good in 5 cases, and fair in 1 case. The excellent and good rate was 93.8%. MRI results showed that TFCC healed in all cases. Conclusion For Atzei-EWAS type 2 TFCC injury, anatomical repair under wrist arthroscopy can restore the anatomical structure of TFCC, effectively relieve wrist pain, improve function, and obtain good effectiveness.
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Affiliation(s)
- Chengyin Lu
- Luoyang Pingle Bone Setting College, Henan University of Chinese Medicine, Luoyang Henan, 471002, P.R.China
| | - Hailong Zhang
- The 2nd Department of Sports Medicine and Arthroscopy, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P.R.China
| | - Laifu Zhang
- Luoyang Pingle Bone Setting College, Henan University of Chinese Medicine, Luoyang Henan, 471002, P.R.China
| | - Pengtao Wang
- Luoyang Pingle Bone Setting College, Henan University of Chinese Medicine, Luoyang Henan, 471002, P.R.China
| | - Xiaohui Wang
- Luoyang Pingle Bone Setting College, Henan University of Chinese Medicine, Luoyang Henan, 471002, P.R.China
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Xu T, Pan X, Mi J. Improved Outside-In Suture through the Joint Capsule to Repair the Palmer I-B Triangular Fibrocartilage Complex Superficial Injury. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:8387813. [PMID: 34804195 PMCID: PMC8598346 DOI: 10.1155/2021/8387813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The treatment of type I-B triangular fibrocartilage complex superficial injury is always a challenge to orthopedists. The traditional outside-in suture method often causes a risk of nervous irritation. We designed a modified outside-in suture through the joint capsule to repair the Palmer I-B triangular fibrocartilage complex superficial injury. METHODS From December 2014 to December 2018, we retrospectively collected the medical records of 18 patients in our hospital who used the modified outside-in suture through the joint capsule to repair type I-B triangular fibrocartilage complex superficial injury. Among them, there were 12 males and 6 females, with an average age of 36.2 years. There were 6 cases on the left side and 12 cases on the right side. Record the healing time of all patients after surgery and the occurrence of related complications, and record the pain visual analogue scale (VAS), grip strength, wrist flexion and extension, radioulnar deviation and forearm rotation range of motion, modified Mayo wrist joint function score, and disability of arm-shoulder-hand (DASH) score before operation and at the last follow-up. RESULTS One patient was lost to follow-up, and a total of 17 patients received the final follow-up. Patients were followed up for 24 to 36 months, with an average of 29.6 ± 3.0 months. No wound infection, nerve damage, or irritation occurred after the operation. At the last follow-up, 15 cases of wrist pain disappeared completely, and 2 cases had mild discomfort during exercise. At the last follow-up, VAS decreased from 3.8 ± 0.7 points before operation to 0.8 ± 0.7 points (P < 0.05); grip strength increased from 15.1 ± 3.1 kg before operation to 23.2 ± 1.5 kg (P < 0.05); wrist flexion and extension, radioulnar deflection, and forearm rotational mobility increased from 116.3 ± 2.2°, 37.0 ± 3.5°, and 141.6 ± 2.2° before operation to 117.2 ± 2.5° (P < 0.05), 38.9 ± 3.0° (P < 0.05), and 142.4 ± 1.9° (P < 0.05), respectively; the modified Mayo wrist joint function score increased from 66.1 ± 3.6 points to 82.5 ± 3.9 points (P < 0.05), of which 10 cases were excellent, 5 cases were good, 2 cases were fair, and the excellent and good rate was 88.2%; DASH score improved from 37.0 ± 5.7 points preoperatively to 8.0 ± 2.5 points (P < 0.05). CONCLUSION The modified outside-in suture through the joint capsule to repair the superficial injury of Palmer I-B triangular fibrocartilage complex has a good clinical effect and is worthy of clinical widespread promotion.
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Affiliation(s)
- Tonglong Xu
- Medical College, Soochow University, Suzhou, China
- Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Xiaoyun Pan
- Medical College, Soochow University, Suzhou, China
- Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Jingyi Mi
- Medical College, Soochow University, Suzhou, China
- Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
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Rabinovich RV, Zelouf DS. Failed Triangular Fibrocartilage Complex Repair and Reconstruction. Hand Clin 2021; 37:507-515. [PMID: 34602130 DOI: 10.1016/j.hcl.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Unsuccessful triangular fibrocartilage complex (TFCC) repair or reconstruction is poorly defined, often stemming from multiple causes, both patient and surgeon-related. Complete evaluation of the patient's psychosocial status and involvement in any litigation claims is essential, as is a thorough history, physical examination, and imaging workup to accurately diagnose TFCC injury, along with any concomitant wrist pathology. Awareness of common complications and technical errors is critical, and preventive treatment strategies should be implemented to minimize these events.
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Affiliation(s)
- Remy V Rabinovich
- New York Hand and Wrist Center - Northwell Health, 210 East 64th Street, 5th Floor, New York, NY 10065, USA.
| | - David S Zelouf
- Philadelphia Hand to Shoulder Center and Thomas Jefferson University Hospitals, 834 Chestnut Street, Suite G-114, Philadelphia, PA 19107, USA
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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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Schachinger F, Farr S. Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review. J Clin Med 2021; 10:2363. [PMID: 34072171 PMCID: PMC8199377 DOI: 10.3390/jcm10112363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
| | - Sebastian Farr
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Speisingertrasse 109, A-1130 Vienna, Austria;
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Jung HS, Kim SH, Jung CW, Woo SJ, Kim JP, Lee JS. Arthroscopic Transosseous Repair of Foveal Tears of the Triangular Fibrocartilage Complex: A Systematic Review of Clinical Outcomes. Arthroscopy 2021; 37:1641-1650. [PMID: 33359818 DOI: 10.1016/j.arthro.2020.12.209] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether arthroscopic transosseous foveal repair of the triangular fibrocartilage complex (TFCC) results in significant and clinically relevant improvement in clinical outcomes including pain and function with low complication and reoperation rates. METHODS We reviewed studies investigating the clinical outcomes of arthroscopic transosseous foveal repair of the TFCC through MEDLINE, Embase, and the Cochrane Library. Studies on TFCC repair performed with an open or capsular technique and combined with other procedures, such as ulnar shortening osteotomy and a wafer procedure, were excluded. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies score. Clinical outcomes were assessed using range of motion, grip strength, and patient-reported outcomes. Clinically relevant improvement was determined using the minimal clinically important difference (MCID). RESULTS A total of 443 unique studies were identified, of which 7 (131 patients) met the inclusion criteria. The mean age ranged from 27 to 37 years, and the mean follow-up period ranged from 23.5 to 31.1 months. The grip strength (as a percentage) increased after foveal repair of the TFCC in all studies (mean difference range, 11.8% to 22.3%). All studies also reported an improvement in the visual analog scale score (mean difference range, -9.8 to -1.88); Modified Mayo Wrist Score (mean difference range, 10.5 to 27); and Disabilities of the Arm, Shoulder and Hand score (mean difference range, -51.8 to -24.48). Considering clinically relevant improvements based on the MCID, 4 of 5 studies reporting the visual analog scale score showed improvements in this score (MCID, 2) and all studies reporting the Disabilities of the Arm, Shoulder and Hand score showed improvements in this score (MCID, 10). Most complications recovered without any treatment, and 3 patients (2.29%) needed a reoperation. CONCLUSIONS Arthroscopic transosseous foveal repair of the TFCC resulted in improvements in grip strength and functional outcomes with low complication and reoperation rates. However, the evidence for which technique produces better clinical outcomes remains limited. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Affiliation(s)
- Hyoung-Seok Jung
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Seong Hwan Kim
- Department of Orthopaedic Surgery, Hyundae General Hospital, Namyangju-si, Republic of Korea
| | - Chan Woo Jung
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Sung Jong Woo
- Department of Orthopaedic Surgery, Guro Narsha Hospital, Seoul, Republic of Korea
| | - Jong Pil Kim
- Department of Orthopaedic Surgery, Dankook University, Cheonan, Republic of Korea
| | - Jae-Sung Lee
- Department of Orthopaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea.
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Feitz R, van der Oest MJW, van der Heijden EPA, Slijper HP, Selles RW, Hovius SER. Patient-reported outcomes and function after reinsertion of the triangular fibrocartilage complex by open surgery. Bone Joint J 2021; 103-B:711-717. [PMID: 33789466 DOI: 10.1302/0301-620x.103b4.bjj-2020-0556.r3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion. METHODS The study involved 274 patients who underwent open repair of the TFCC between December 2013 and December 2018. The patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and scored pain and function using a visual analogue scale (VAS). Range of motion (ROM) was assessed by experienced hand therapists. RESULTS Clinically significant improvements were reported in pain, function, and grip strength in 220 patients (80%) three and 12 months postoperatively. CONCLUSION These data will help surgeons to make decisions about the outcomes of open repair of the TFCC and to counsel patients appropriately. Level of evidence: III Cite this article: Bone Joint J 2021;103-B(4):711-717.
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Affiliation(s)
- Reinier Feitz
- Hand and Wrist Center, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Mark J W van der Oest
- Hand and Wrist Center, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, Netherlands.,Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Elisabeth P A van der Heijden
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Plastic, Reconstructive, and Hand Surgery, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Netherlands
| | - Harm P Slijper
- Hand and Wrist Center, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, Rotterdam, Netherlands.,Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Steven E R Hovius
- Hand and Wrist Center, Xpert Clinics, Amsterdam, Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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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: 10] [Impact Index Per Article: 3.3] [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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Abstract
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.
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Affiliation(s)
- John C. Dunn
- William Beaumont Army Medical Center, El Paso, TX, USA
| | - Michael M. Polmear
- William Beaumont Army Medical Center, El Paso, TX, USA,Michael M. Polmear, Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79920-5001, USA.
| | - Leon J. Nesti
- Walter Reed National Military Medical Center, Bethesda, MD, USA,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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McNamara CT, Colakoglu S, Iorio ML. A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment. J Hand Microsurg 2020; 12:116-122. [PMID: 32788827 PMCID: PMC7410809 DOI: 10.1055/s-0040-1713580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV.
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Affiliation(s)
- Colin T. McNamara
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Salih Colakoglu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Matthew L. Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
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Robba V, Fowler A, Karantana A, Grindlay D, Lindau T. Open Versus Arthroscopic Repair of 1B Ulnar-Sided Triangular Fibrocartilage Complex Tears: A Systematic Review. Hand (N Y) 2020; 15:456-464. [PMID: 30667271 PMCID: PMC7370382 DOI: 10.1177/1558944718815244] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Arthroscopic Ligament-specific Repair for Triangular Fibrocartilage Complex Foveal Avulsion: A Novel Technique. Tech Hand Up Extrem Surg 2020; 24:175-181. [PMID: 32412983 DOI: 10.1097/bth.0000000000000292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Abstract
Distal radioulnar joint (DRUJ) instability is often an underestimated or missed lesion which may entail fatal consequences. The triangular fibrocartilage complex is a biomechanically very important stabilizer of the DRUJ and guarantees unrestricted range of motion of the forearm. To detect DRUJ instability a systematic examination is of uppermost importance. The contralateral healthy arm will be used for comparison during clinical examination. X-rays are required to exclude osseous lesions or deformities. Computed tomography of both wrists in neutral forearm rotation, supination, and pronation may be necessary to verify DRUJ instability in ambiguous situations. Following a systematic clinical examination wrist and DRUJ arthroscopy detects lesions definitely. Tears of the distal radioulnar ligaments which entail DRUJ instability should be repaired preferably anatomically. Ulnar-sided ligament ruptures which cause instability are detected more often than radial-sided ones. Osseous ligament avulsions are mostly refixated osteosynthetically. Ligamentous tears of the distal radioulnar ligaments may be reconstructed using anchor suture or transosseous refixation. Secondary procedures such as tendon transplants are necessary for anatomical reconstruction in cases of unrepairable ligament tears.
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Andersson JK, Hagert EM, Fridén J. Patients With Triangular Fibrocartilage Complex Injuries and Distal Radioulnar Joint Instability Gain Improved Forearm Peak Pronation and Supination Torque After Reinsertion. Hand (N Y) 2020; 15:281-286. [PMID: 30081654 PMCID: PMC7076604 DOI: 10.1177/1558944718793198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Forearm peak pronation and supination torque measurements are reduced up to 30% in patients with triangular fibrocartilage complex (TFCC) 1B injuries with concomitant distal radioulnar joint (DRUJ) instability. The aim of our study was to evaluate whether patients with TFCC 1B injuries, with concomitant DRUJ instability, improve in forearm peak pronation and supination torque following TFCC reinsertion surgery where postoperative DRUJ stability was achieved. Methods: We report a retrospective case series with short-term follow-up (20 months) of the postoperative forearm peak torque in pronation and supination in 11 patients (9 women/2 men, average age at surgery 32 years) operated on by TFCC reinsertion. Two of the initial 13 patients were later on reoperated due to recurring DRUJ instability and were therefore excluded in this follow-up study. Nine were treated by arthroscopic TFCC reinsertion and 2 by open technique. The forearm peak pronation and supination torque were measured pre- and postoperatively and compared with the uninjured side. Results: On average, a 16% improvement of the forearm peak torque was achieved in the injured wrist, as well as clinically assessed DRUJ stability. Functional postoperative improvement was noted in all patients, with reduced pain, good satisfaction, and acceptance of the surgery and the final result. Conclusion: We conclude that patients with TFCC injuries and DRUJ instability gain improved forearm peak pronation and supination torque after reinsertion. We also conclude that forearm peak pronation and supination torque is a valuable tool in the preoperative diagnostics of TFCC injuries with DRUJ instability as well as in the postoperative follow-up.
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Affiliation(s)
- Jonny K. Andersson
- SportsMed, Göteborg, Sweden,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Jonny K. Andersson, SportsMed, Carlanderska Hospital, SE-405 45 Göteborg, Sweden.
| | - Elisabet M. Hagert
- Karolinska Institute, Stockholm, Sweden,ARCADEMY Stockholm, Sophiahemmet Hospital, Stockholm, Sweden
| | - Jan Fridén
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Sahlgrenska University Hospital, Mölndal, Sweden,Swiss Paraplegic Centre, Nottwil, Switzerland
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Auzias P, Camus EJ, Moungondo F, Van Overstraeten L. Arthroscopic-assisted 6U approach for foveal reattachment of triangular fibrocartilage complex with an anchor: Clinical and radiographic outcomes at 4 years' mean follow-up. HAND SURGERY & REHABILITATION 2020; 39:193-200. [PMID: 32032802 DOI: 10.1016/j.hansur.2020.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
The main objective of this study was to evaluate the long-term clinical and radiological outcomes of arthroscopic-assisted foveal repair of proximal triangular fibrocartilage complex (TFCC) tears with an anchor. The secondary objective was to look for ligament damage associated with TFCC tears. Twenty-four patients who underwent foveal repair of the TFCC were evaluated retrospectively: 16 stage 2 and 8 stage 3 in the Atzei-EWAS classification. The TFCC was repaired with an anchor using an expanded 6U approach. Systematic testing of intrinsic and extrinsic ligaments was performed. The assessment criteria were pain on a visual analog scale (VAS), wrist joint range of motion, grip strength and pronation-supination strength, and the QuickDASH and PRWE outcome scores. X-rays were also taken to assess anchor position and to look for distal radioulnar (DRU) joint damage. The average follow-up was 44 months. After the surgical repair, pain was reduced (7.36±1.3 preoperatively vs. 0.69±1.3 postoperatively; P<0.001), the QuickDASH score improved (52.1±16 vs. 21.7±7; P<0.001), the PRWE score improved (83.7±35 vs. 9.3±12; P<0.001) as did strength (35 vs. 43kg; P<0.001). The DRU joint stability was also significantly improved. The time away from work was 2.6 months. During the arthroscopy exploration, 25% of patients had an ulnotriquetral ligament lesion and 8% had an ulnolunar ligament lesion in combination with their TFCC tear. Fifteen anchors were positioned in the anatomical fovea (62%). No DRU joint damage was noted. Six patients had neurapraxia of the dorsal branch of the ulnar nerve, although it recovered spontaneously. One patient still had hypoesthesia of the ulnar side of the fifth finger at 48 months. Arthroscopic-assisted foveal repair of the TFCC yields good results in terms of pain, strength and DRU joint stability. In one-quarter of cases, TFCC foveal tears are associated with lesions of the ulnotriquetral ligament. There is no long-term degeneration of the DRU joint.
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Affiliation(s)
- P Auzias
- Service d'orthopédie, CHRU de Lille, hôpital Roger Salengro, rue du Professeur Emile-Laine, 59037 Lille cedex, France.
| | - E J Camus
- Polyclinique du Val de Sambre, 162, route de Mons, 59600 Maubeuge, France
| | - F Moungondo
- Hôpital Erasme, ULB, route de Lennik, 1070 Bruxelles, Belgium
| | - L Van Overstraeten
- Hôpital Erasme, ULB, route de Lennik, 1070 Bruxelles, Belgium; Hand and foot surgery unit, 9, rue Pierre-Caille, Tournai, Belgium
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Bonhof-Jansen EDJ, Kroon GJ, Brink SM, van Uchelen JH. Rehabilitation with a stabilizing exercise program in triangular fibrocartilage complex lesions with distal radioulnar joint instability: A pilot intervention study. HAND THERAPY 2019. [DOI: 10.1177/1758998319861661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- EDJ Bonhof-Jansen
- Department of Hand Therapy, Isala Hand and Wrist Center, Zwolle, The Netherlands
| | - GJ Kroon
- Department of Hand Therapy, Isala Hand and Wrist Center, Zwolle, The Netherlands
| | - SM Brink
- Department of Rehabilitation Medicine, Isala Hand and Wrist Center, Zwolle, The Netherlands
| | - JH van Uchelen
- Handsurgeon, Xpert Clinic, Velp/Apeldoorn, The Netherlands
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Robba VI, Karantana A, Fowler APG, Diver C. Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study. J Hand Surg Eur Vol 2019; 44:572-581. [PMID: 30741080 DOI: 10.1177/1753193419826459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Vanessa I Robba
- 1 Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Nottingham, UK
| | - Alexia Karantana
- 2 Centre for Evidence-Based Hand Surgery, University of Nottingham, Nottingham, UK
| | | | - Claire Diver
- 4 Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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Pfanner S, Diaz L, Ghargozloo D, Denaro V, Ceruso M. TFCC Lesions in Children and Adolescents: Open Treatment. J Hand Surg Asian Pac Vol 2019; 23:506-514. [PMID: 30428785 DOI: 10.1142/s2424835518500509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique. METHODS Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated. RESULTS The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair. CONCLUSIONS This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.
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Affiliation(s)
- Sandra Pfanner
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
| | - Lorenzo Diaz
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Dariush Ghargozloo
- ‡ Orthopedics and Traumatology Department, ASST Valcamonica, Esine Hospital, Esine (BS), Italy
| | - Vincenzo Denaro
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Massimo Ceruso
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
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Surgical Management of Triangular Fibrocartilage Complex Lesions: A Review of Outcomes. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2019. [DOI: 10.1016/j.jhsg.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abe Y, Fujii K, Fujisawa T. Midterm Results after Open versus Arthroscopic Transosseous Repair for Foveal Tears of the Triangular Fibrocartilage Complex. J Wrist Surg 2018; 7:292-297. [PMID: 30174985 PMCID: PMC6117178 DOI: 10.1055/s-0038-1641720] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
Purpose Various surgical procedures for foveal tears of the triangular fibrocartilage complex (TFCC) have been reported, and the procedures can be grossly divided into open and arthroscopic repair. The surgical results of both procedures were compared. Materials and Methods Twenty-nine patients underwent repair of a TFCC foveal tear. The 13 men and 16 women were in the age range of 14 to 72 years (average age, 30 years). Five patients had a history of distal radius fractures that healed uneventfully with nonoperative treatment. The mean duration of symptoms before surgery was 7.1 months. The procedure for repair consisted of 8 open repairs and 21 arthroscopic repairs. In both procedures, the TFCC was repaired transosseously to the ulna. The mean follow-up period was 34.4 (range, 24-70) months. The patients' pain, range of motion (ROM), grasping power, ulnar head instability, Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and Mayo modified wrist score (MMWS) were evaluated. The operating time was also compared. Results There were no significant differences between the groups in pain, ROM, grasping power, ulnar head instability, and DASH. The MMWS was excellent in 8 patients in the open repair group, with 18 excellent and 3 good in the arthroscopic repair group. The mean operating time was significantly shorter for arthroscopic repair than for open repair. Conclusion Satisfactory outcomes were achieved for both open and arthroscopic repair techniques in the midterm. If a surgeon becomes familiar with the arthroscopic repair, the arthroscopic technique would be more feasible than the open repair in terms of technical facility and shortening of the operating time. Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Yukio Abe
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
| | - Kenzo Fujii
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
| | - Takeyoshi Fujisawa
- Department of Orthopaedic Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
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Andersson JK, Åhlén M, Andernord D. Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review. J Exp Orthop 2018. [PMID: 29536282 PMCID: PMC5849747 DOI: 10.1186/s40634-018-0120-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background and purpose To investigate the outcome of open versus arthroscopic repair of injuries of the triangular fibrocartilage complex (TFCC). Methods An electronic literature search of articles published between January 1, 1985, and May 26, 2016, in PubMed, Embase, and the Cochrane Library was carried out in May 2016 and updated in March and December 2017. Studies comparing open and arthroscopic repair of TFCC injury with a mean follow up of more than 1 year were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodological quality of the included articles was assessed with the Cochrane Collaboration’s tool for assessing risk of bias. The primary outcome measure was the rate of postoperative distal radioulnar joint (DRUJ) re-instability. Secondary outcome measures were range of motion (ROM), grip strength, residual pain, functional wrist scores and the rates of complications and re-operations. Results A total of 868 articles were identified by the electronic search. After duplicate removal and subsequent study selection, a total of two studies were included in this systematic review. The methodological quality of the included articles displayed risks of bias. There was no difference in DRUJ re-instability between open and arthroscopic repair of the TFCC. There were no differences in obtained postoperative ROM, grip strength or values in functional outcome scores, between open and arthroscopic TFCC repair in the two included studies, except for the Disability of the Arm Shoulder and Hand (DASH) questionnaire - in favor of arthroscopic surgery - in one of the included studies. Conclusions This systematic review shows comparable results between open and arthroscopic repair of the TFCC, in terms of DRUJ re-instability and functional outcome scores. There is insufficient evidence to recommend one technique over the other in clinical practice. There is an immense lack of comparison studies with high level of evidence in the area of wrist ligament repair and reconstruction, including TFCC-injuries and DRUJ-instability.
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Affiliation(s)
- Jonny K Andersson
- Department of Hand Surgery, Sahlgrenska University Hospital, SE-413 45, Göteborg, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
| | - Martina Åhlén
- Department of Hand Surgery, Sahlgrenska University Hospital, SE-413 45, Göteborg, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Daniel Andernord
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Vårdcentralen Gripen, Karlstad, Sweden.,Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden
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The status of triangular fibrocartilage complex after the union of distal radius fractures with internal plate fixation. INTERNATIONAL ORTHOPAEDICS 2018; 42:1917-1922. [PMID: 29476211 DOI: 10.1007/s00264-018-3793-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance. METHODS Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old. RESULTS Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC. CONCLUSIONS A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.
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Affiliation(s)
- Maria Moloney
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Sweden
| | - Simon Farnebo
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Sweden
| | - Lars Adolfsson
- Department of Clinical and Experimental Medicine, Linköping University, Sweden
- Department of Orthopaedics, Linköping University, Sweden
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46
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Distal radioulnar joint instability. HAND SURGERY & REHABILITATION 2017; 36:305-313. [DOI: 10.1016/j.hansur.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW The goal of this manuscript is to review key historic and recent literature regarding extensor carpi ulnaris (ECU), triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) injuries, particularly in athletes. RECENT FINDINGS Many recent studies examining the ECU focus on clinical and radiographic diagnosis. Several physical exam findings are described in addition to the use of MRI and US. Imaging studies must be clinically correlated due to high incidence of findings in asymptomatic patients. In regard to the TFCC/DRUJ, there are numerous recent studies that support the use of MRA as an adjunctive diagnostic study. There are also a number of repair constructs that are described for the various different kinds of TFCC pathology reviewed here. In summary, there are a number of options for the diagnosis and treatment of ulnar-sided wrist pain. Patient factors, especially in the athletic population, must be taken into account when approaching any patient with these pathologies.
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Ma CH, Lin TS, Wu CH, Li DY, Yang SC, Tu YK. Biomechanical Comparison of Open and Arthroscopic Transosseous Repair of Triangular Fibrocartilage Complex Foveal Tears: A Cadaveric Study. Arthroscopy 2017; 33:297-304. [PMID: 28034486 DOI: 10.1016/j.arthro.2016.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/16/2016] [Accepted: 10/26/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To biomechanically compare the stability between open repair and arthroscopic transosseous repair technique for reattachment of the foveal triangular fibrocartilage complex (TFCC). We also evaluated the feasibility of a new aiming device for the creation of 2 bone tunnels simultaneously during the arthroscopic technique. METHODS Six matched pairs of fresh-frozen forearm cadaver specimens were prepared for testing. Group I specimens were treated by open repair with suture anchor. Group II specimens were treated by arthroscopic transosseous suture with a new aiming device. Before and after disruption of the TFCC fovea and after its repair, dorsal and palmar translation of the ulna was measured in both groups in response to a load (3 kg) applied in the palmar and then in the dorsal direction. The total translation of the ulna was calculated as the sum of the mean dorsal and palmar translations. RESULTS The mean total ulnar translation before and after TFCC disruption, and after TFCC repair was 5.94 ± 2.16 mm, 9.08 ± 2.64 mm, and 6.04 ± 2.18 mm, respectively. The specimens demonstrated a significant increase in the total translation of the ulna after disruption of the ulnar attachment of TFCC (P = .003), whereas a significant decrease was observed after TFCC foveal repair (P = .003). The median percentage of eliminated translation after TFCC repair was 64% and 172%, respectively, in groups I and II (P = .043). CONCLUSIONS The athroscopic transosseous suture technique demonstrated superior repair efficacy to the open repair technique in terms of biomechanical strength. This cadaveric study also demonstrated the feasibility of a new aiming device. CLINICAL RELEVANCE When making decisions about TFCC foveal repair, arthroscopic transosseous suture technique may provide better biomechanical strength than the open repair technique.
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Affiliation(s)
- Ching-Hou Ma
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Ting-Sheng Lin
- Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan.
| | - Dong-Yi Li
- Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Chieh Yang
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
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Schmelzer-Schmied N. [Arthroscopic refixation of TFCC by bone screw anchor]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2016; 28:251-62. [PMID: 27379856 DOI: 10.1007/s00064-016-0455-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The goal of this operation technique is a stable refixation of the triangular fibrocartilage complex (TFCC) to the fovea ulnaris. The stability of the distal radio-ulnar joint (DRUJ) should be re-established. The patients pain and the feeling of instability should be reduced. INDICATIONS Lesions of the foveal component of the TFCC resulting in DRUJ instability. Combined lesions of both components of the TFCC. Complete detachment of the TFCC from the ulna either without fracture of the styloid process of the ulna or with fracture (floating styloid). CONTRAINDICATIONS Severe lacerations of the TFCC and clinically relevant arthrosis of the DRUJ. Severely osteoporotic bone. SURGICAL TECHNIQUE Following diagnostic arthroscopy and performance of stability control of the TFCC with a palpation hook, reduction of the DRUJ with supination position of the wrist. Bone anchor fixation through the direct foveal portal (DF). Under arthroscopic control through the 3/4 portal, the suture from the DF portal is placed through the TFCC. Pull out and tie the strands through the 6 U portal. POSTOPERATIVE MANAGEMENT Restriction of rotation of the forearm in a Munster cast or special cast brace for 6 weeks. Self-controlled exercise of the wrist after 6 weeks. Physiotherapy and strength building 8 weeks postoperatively. RESULTS Clinical studies of this technique showed a significant amelioration of pain perception, improved range of motion and DASH score in all patients after anchor fixation. The results are comparable to other techniques. All patients returned to work after the operation. Accordingly, using this technique a very good stabilization of the DRUJ with low complications can be achieved.
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Affiliation(s)
- N Schmelzer-Schmied
- Orthopädie Rosenberg (OR), Rorschacherstrasse 150, 9006, St Gallen, Schweiz.
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50
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Seo JB, Kim JP, Yi HS, Park KH. The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy. J Hand Surg Am 2016; 41:615-23. [PMID: 27039349 DOI: 10.1016/j.jhsa.2016.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/24/2016] [Accepted: 02/16/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare the results of arthroscopic peripheral repair (AR) and arthroscopic debridement (AD) for the treatment of chronic unstable triangular fibrocartilage complex (TFCC) tears in ulnar-positive patients undergoing ulnar-shortening osteotomy (USO). METHODS A total of 31 patients who underwent arthroscopic treatments combined with USO for unstable TFCC tears and were followed-up at a minimum of 24 months were included in this retrospective cohort study. Fifteen patients were treated with AR, and 16 patients were treated with AD while at the same time undergoing a USO. Outcome measures included wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, and overall outcomes according to the modified Mayo wrist scoring system. In addition, a stress test to assess distal radioulnar joint (DRUJ) stability was performed before and after surgery to compare the 2 cohorts. RESULTS Both respective cohorts showed significant improvements in grip strength and subjective scores at the final follow-up. Grip strength, DASH, and PRWE scores were better in the AR group than in the AD group. The recovery rate from DRUJ instability observed during the preoperative examination was superior in the AR group. CONCLUSIONS Both AD and AR of the TFCC combined with USO are reliable procedures with satisfactory clinical outcomes for unstable TFCC tears in ulnar-positive patients. However, AR of the TFCC is suggested if DRUJ stability is concomitantly compromised. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Joong-Bae Seo
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, Korea; Department of Kinesiology and Medical Science, Graduate School, Dankook University, Cheonan, Korea
| | - Jong-Pil Kim
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, Korea; Department of Kinesiology and Medical Science, Graduate School, Dankook University, Cheonan, Korea.
| | - Hyung-Suk Yi
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, Korea
| | - Kwang-Hee Park
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, Korea
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