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

Ulnar Impaction Syndrome and TFCC Injury: Their Relationship and Management

Ulnar-sided wrist pain can be caused by a number of problems, including ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) injury. Multiple studies have described the diagnostic criteria for UIS and TFCC injuries, and excellent surgical outcomes have been reported for each condition. Few studies have examined the extent to which the two independent conditions cooccur, and little is known about their relationship. Based on theories in the literature and clinical experience, we propose the possibility of TFCC injury as the cause and result of UIS in this review.

Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs

OBJECTIVE

This study is to assess the diagnostic performance of magnetic resonance imaging (MRI) findings for type 1B triangular fibrocartilage complex (TFCC) tear of the wrist.

MATERIALS AND METHODS

This study retrospectively enrolled 78 patients to examine the diagnostic performance of preoperative MRI examinations in patients with type 1B TFCC tears. Thirty-nine participants had confirmed type 1B TFCC tear. The control group included 39 patients who were randomly selected from 1157 patients who underwent MRI for wrist pain. Both groups underwent a review of 19 MRI findings by two independent radiologists, and the correlation between each diagnostic finding and type 1B TFCC tear was assessed using the chi-squared test. The 19 MRI findings comprised eight primary signs of abnormalities in the distal or proximal lamina, in conjunction with 11 secondary signs suggestive of abnormalities in the surrounding structures.

RESULTS

The TFCC tear group demonstrated a significantly higher incidence of two primary MRI signs, i.e., fiber discontinuity and signal alteration in the distal lamina, as observed by both readers (R1, 74.4% vs. 38.5%, p = 0.003, and 87.2% vs. 43.6%, p < 0.001; R2, 74.4% vs. 35.9%, p = 0.001, and 87.2% vs. 53.8%, p < 0.003, respectively). Reader 2 identified a higher prevalence of two additional primary MRI signs: fiber discontinuity and signal alteration in the proximal lamina (all p < 0.05). None of the 11 secondary MRI signs demonstrated statistically significant associations with type 1B TFCC.

CONCLUSION

MRI manifestations of fiber discontinuity and signal alteration in the distal lamina may provide predictive markers for type 1B TFCC wrist tear.

The Combined Procedure of Ulnar Metaphyseal Shortening Osteotomy With Triangular Fibrocartilage Complex Foveal Knotless Repair

Ulnar impaction syndrome (UIS) and triangular fibrocartilage complex (TFCC) tear are common causes of ulnar-sided wrist pain. As a standard surgical treatment, ulnar-shortening osteotomy (USO) and TFCC repair are used respectively. Patient spectrums of UIS accompanied by distal radioulnar joint instability or traumatic TFCC foveal tear with UIS symptoms exist, and both USO and TFCC repair are necessary for treating some of these patients. However, there have been few reports on the procedure for performing these 2 operations concurrently. We introduce a combined procedure to concurrently perform USO and TFCC repair. We performed a USO in the ulnar metaphysis using a locking plate and open TFCC knotless repair using a suture anchor at the ulnar fovea. In this technique, USO is conducted in the metaphysis, which is favorable to union, using a small plate that is easy to handle, and knotless TFCC repair can be performed simultaneously through a single small incision.

What Is the Effect of the Ulnar-Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar-Side Triangular Fibrocartilage Complex Tear?

PURPOSE

To compare the outcomes of arthroscopic repair of peripheral ulnar-side triangular fibrocartilage complex (TFCC) tears between patients with and without ulnar-plus variance (UPV) and to identify factors associated with index surgery failure in these patients.

METHODS

We retrospectively analyzed 50 consecutive patients who underwent arthroscopic repair of peripheral ulnar-side TFCC tears from June 2014 to February 2018. We selected patients who were aged at least 18 years and underwent arthroscopic repair of peripheral ulnar-side TFCC tears. We excluded those with a fractured or dislocated wrist, ulnar impaction syndrome, degenerative or inflammatory arthritis of the wrist, or neurologic conditions that affect upper-extremity function, as well as those who received less than 12 months' follow-up. We evaluated the patients with a visual analog scale for pain in 3 domains (overall, with hard work, and at rest), the Patient-rated Wrist Evaluation, range of motion, and grip strength. Clinical outcomes and arthroscopic findings were compared between patients with and without UPV (UPV group and non-UPV group, respectively). We calculated the relative risk and 95% confidence interval for younger age (<30 years), sex, UPV, and coexisting degenerative central TFCC tear (type 2 tear) to determine the risk factors for arthroscopic repair failure.

RESULTS

No significant differences were noted between the 2 groups regarding visual analog scale pain and Patient-rated Wrist Evaluation scores and rates of excellent or improved outcomes (P > .05). Arthroscopic repair failure was found in 4 patients. A coexisting type 2 TFCC tear was the only significant risk factor (relative risk, 49.5; 95% confidence interval, 2.94-83.96; P = .007) for arthroscopic repair failure.

CONCLUSIONS

UPV did not significantly affect the outcomes of arthroscopic repair of peripheral ulnar-side TFCC tears. However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Editorial Commentary: Ulnar Variance Is Not the Sole Determinant of Arthroscopic Wrist Triangular Fibrocartilage Complex Repair Outcome: Considering the Forest From the Ulnar-Positive Tree

When choosing the best treatment option for patients with tears of the triangular fibrocartilage complex, there are multiple patient factors that should be carefully considered. The role of ulnar variance is often overemphasized when attempting to predict the success of arthroscopic repair. In practice, variables such as the age of the patient and location and nature of the tear as traumatic or degenerative should primarily drive the decision between arthroscopic repair and primary ulnar-shortening osteotomy. Arthroscopic repair should generally be avoided in favor of ulnar-shortening osteotomy in patients with degenerative tears and evidence of ulnar impaction syndrome. However, for acute, traumatic, ulnar-sided tears in young patients, arthroscopic repair remains an effective treatment option regardless of ulnar variance.

Open Versus Arthroscopic Repair of 1B Ulnar-Sided Triangular Fibrocartilage Complex Tears: A Systematic Review

Background: Peripheral 1B tears of the triangular fibrocartilage complex (TFCC) can result in distal radioulnar joint (DRUJ) instability. In the context of associated DRUJ instability, combined evidence supports successful outcomes for peripheral tear repair. Methods: The aim of this systematic review (SR) was to compare the surgical treatment of 1B TFCC tears via arthroscopic versus open methods of repair. The primary outcome measure was restored DRUJ stability. The secondary outcome measures included patient-reported outcomes and clinical outcome measures. An electronic database search of Ovid Embase, PubMed, and the Cochrane Central Register of Controlled Trials was performed to cover a 20-year period. Two authors independently screened records for eligibility and extracted data. Results: Only 3 studies met the strict inclusion criteria, highlighting the poor evidence base for TFCC 1B repairs. Hence, a "secondary analysis" group was developed with modified inclusion criteria which included a further 7 studies for analysis. Pooled data from the primary and secondary analysis groups demonstrated that postoperative DRUJ stability was achieved following open repair in 84% (76/90) of cases and following arthroscopic repair in 86% (129/150) of cases. Conclusions: This SR demonstrates a current lack of high-quality evidence required to draw firm conclusions on the merits of arthroscopic versus open repair of 1B TFCC tears. There is no scientific evidence to suggest superiority of one technique over the other, albeit some surgeons and authors may express a strong personal view.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV.

Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear

PURPOSE

Arthroscopic repair of a peripheral triangular fibrocartilage complex (TFCC) tear is a promising, minimally invasive surgical technique, especially in patients with symptomatic distal radioulnar joint (DRUJ) instability. The purpose of this study was to evaluate the clinical result of arthroscopic one-tunnel transosseous foveal repair for peripheral TFCC tears.

METHODS

Sixteen patients who underwent TFCC foveal repair were retrospectively evaluated. The mean follow-up period was 31.1 months. The torn TFCC of all patients was repaired with the arthroscopic one-tunnel transosseous foveal repair technique. Postoperative outcomes were evaluated using the visual analogue scale (VAS) for pain, wrist range of motion, grip strength, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and postoperative complications.

RESULTS

On arthroscopic examination, all 16 patients showed Palmer 1B type peripheral TFCC tears with foveal disruption. Among them, 13 patients had a proximal component TFCC tear (Atzei class 3) and 3 patients had a complete TFCC tear (Atzei class 2). At the final follow-up, the mean range of the pronation-supination arc (P = 0.03) and grip strength (P = 0.001) was significantly increased. Twelve patients had normal stability of the DRUJ and six patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 3.7 to 0.8 (P = 0.001). The modified Mayo wrist (P = 0.001) and Quick DASH (P = 0.001) scores showed significant functional improvement. No surgery-related complications occurred.

CONCLUSIONS

The present study shows that arthroscopic one-tunnel transosseous repair is a good treatment strategy for TFCC foveal tears in terms of reliable pain relief, functional improvement, and re-establishment of DRUJ stability.

Hardware Location and Clinical Outcome in Ulna Shortening Osteotomy

The purpose of this study was to investigate the influence of plate location during ulna shortening osteotomy on the incidence of hardware irritation and clinical outcome.

METHODS

Forty patients (17 women, 23 men; mean age, 47 years) who underwent a shortening osteotomy of the ulna due to idiopathic ulna impaction syndrome were examined after a mean of 36 months. All complications and secondary procedures were extracted from the patients' records.

RESULTS

The rate of hardware removal was higher in patients who had a dorsal placement of the plate in comparison with ulnar or palmar placements, although this difference was not statistically significant. Apart from hardware irritation, there were 4 nonunions, 1 secondary osteoarthritis of the distal radioulnar joint, and 1 case of chronic irritation of the dorsal branch of the ulnar nerve, which required secondary surgery. The incidence of secondary surgery other than hardware removal was not significantly related to the original location of the plate.

CONCLUSIONS

Secondary surgery after ulnar shortening osteotomy is common. However, we found no difference in clinical outcomes based on plate location.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

How does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex?

BACKGROUND

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC.

QUESTIONS/PURPOSES

The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score.

METHODS

Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24-210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed.

RESULTS

Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2=0.21; β=-0.33; 95% CI, -0.11 to 0.01; p=0.01) and between the magnitude of change in the TFC angle and the extent of ulnar shortening (R2=0.18; β=-0.29; 95% CI, -5.8 to 0.29; p=0.03). The Mayo wrist score was not correlated with the percent change in TFC thickness or the magnitude of change in the TFC angle.

CONCLUSIONS

These results suggest that, in patients with TFCC injury with a smaller preoperative ulnar variance, a high residual potential for regeneration in the disc proper was seen after ulnar shortening osteotomy, and correlated with the extent of ulnar shortening and the suspension effect on TFC. However, there was no correlation between disc regeneration or the suspension effect on TFC and the Mayo wrist score.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Minimally invasive approaches to ulnar-sided wrist disorders

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

Revision wrist arthroscopy after failed primary arthroscopic treatment

Background The etiologies and outcomes of cases of failed therapeutic wrist arthroscopy have not been well-described to date. Purpose The purposes of this study were to identify common preventable patterns of failure in wrist arthroscopy and to report outcomes of a series of revision arthroscopy cases. Patients and Methods Retrospective review of 237 wrist arthroscopies revealed 21 patients with a prior arthroscopy for the same symptoms, of which 16 were assessed by questionnaires and physical exam for this study. Results Six of sixteen patients (38%) had unrecognized dynamic ulnar impaction after débridement of triangular fibrocartilage complex (TFCC) tears, which resolved with arthroscopic wafer resection. Five (31%) had persistent distal radioulnar joint (DRUJ) instability after initial treatment of TFCC tears, requiring arthroscopic repair at revision. Four (25%) experienced diffuse dorsal wrist pain initially diagnosed as TFCC tears, but dynamic scapholunate ligament injuries were found and addressed with radiofrequency (RF) shrinkage at reoperation. Two (13%) required further resection of the radial styloid, after initial débridement was insufficient to correct radioscaphoid impingement. At a mean of 4.8 years after repeat arthroscopy (range, 1.5-13.4 years), this cohort had significant improvements in pain and satisfaction with outcomes after revision arthroscopy. Conclusions The most common indications for repeat wrist arthroscopy were ligamentous instability (of the DRUJ or scapholunate ligament) and osteoarthritis (from dynamic ulnar impaction or radioscaphoid impingement). Although revision wrist arthroscopy may yield acceptable outcomes, careful assessment of stability and cartilage wear at index procedure is crucial.

LEVEL OF EVIDENCE

 Level IV Therapeutic.

Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient

PURPOSE

Our aim was to evaluate the clinical results of patients treated by arthroscopically assisted reconstruction of foveal avulsion injury of the triangular fibrocartilage complex (TFCC) using a suture anchor.

METHODS

We retrospectively reviewed the results of 15 patients (11 men and 4 women; mean age, 30.5 years) who underwent surgical procedures for the treatment of TFCC foveal avulsion at our hospital. The patients were followed up for a mean of 29 months. The patients had TFCC foveal avulsion caused by sprains (n = 8), falls (n = 4), playing baseball (n = 2), and a motor vehicle accident (n = 1). All the patients underwent magnetic resonance imaging. Radiographs obtained to assess ulnar variance (UV), ulnar-dorsal subluxation, and function of the wrist based on grip power; Disabilities of the Arm, Shoulder and Hand score; and Mayo wrist score were examined for all patients both preoperatively and postoperatively.

RESULTS

On preoperative magnetic resonance imaging, TFCC foveal avulsion was observed in 13 of 15 cases. The mean UV value based on preoperative simple radiographic findings was 1.7 ± 1.0 mm, and dorsal subluxation at the distal ulna improved from 2.9 ± 3.0 mm to 0.2 ± 0.9 mm (P = .017). In all cases the distal radioulnar joint instability disappeared postoperatively. Grip power (compared with the uninvolved limb) was 79.3% preoperatively and 82.9% postoperatively (P = .086). The Disabilities of the Arm, Shoulder and Hand scores were 28.4 points preoperatively and 16.6 points postoperatively (P = .061). The Mayo wrist scores were excellent in 10 cases, good in 2, and fair in 3, and the mean score improved significantly from 64 points preoperatively to 84 points postoperatively (P = .007).

CONCLUSIONS

Arthroscopic-assisted suture anchor reattachment of the TFCC in patients with traumatic TFCC foveal avulsion can prevent or reduce distal radioulnar joint instability and reduce pain even in chronic cases with positive UV.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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

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

Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer Type 1B) tears: a comparison between short- and midterm results

PURPOSE

To compare short- and midterm functional and subjective outcomes of arthroscopically repaired Palmer 1B tears.

METHODS

At 2 time points, we evaluated 49 patients with Palmer 1B tears who underwent arthroscopic repair. We examined 46 patients (23 males and 23 females) in the short-term at an average of 11 months (range, 6-23 mo) postoperatively. In a second midterm follow-up, we examined 40 patients (20 males and 20 females) an average of 4.8 years (range, 4.2-5.9 y) after repair. Between short- and midterm follow-ups, 6 patients underwent an ulnar-shortening osteotomy to alleviate persistent ulnar-sided symptoms. Objective and subjective evaluation included the determination of range of motion, grip strength, pain, and wrist scores (modified Mayo wrist score and Disabilities of Arm, Shoulder, and Hand score).

RESULTS

Compared with short-term repair results, midterm outcomes showed a further improvement in pain, wrist scores, grip strength, and motion. Neither static nor dynamic ulnar variance was correlated to preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand scores, short-term modified Mayo wrist scores, or need for ulnar-shortening osteotomy. Five patients improved only after having received an ulnar shortening osteotomy.

CONCLUSIONS

After repair of Palmer 1B lesions, patients continued to improve in function and comfort at least into the second year, although some needed to have the ulna shortened to achieve this result.

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture: six cases related to triangular fibrocartilage complex injury

INTRODUCTION

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture even after union is a matter of concern. There could be various reasons for this persistent pain like arthritis, instability, fractures and non-union. We correlate our findings of physical examination and wrist arthroscopy as triangular fibrocartilage complex injury to be one of the causes of this persistent pain.

PATIENTS

Six subjects who had persistent ulnocarpal joint pain and tenderness after triquetral dorsal chip fracture, despite 2 months of conservative treatment, were subjected to physical tests. If the physical examination yields positive results, then magnetic resonance imaging followed by arthroscopic treatment was performed. The six patients were then evaluated using the visual analogue scale, the Mayo modified wrist score, and the grip strength test.

RESULTS

Triangular fibrocartilage complex (TFCC) injury was observed in all six cases and partial TFCC resection and synovectomy were performed. Analysis of the visual analogue scale, Mayo modified wrist score, and grip strength test data revealed statistically significant improvements (P < 0.05).

CONCLUSION

In addition to several causes reported in the published literature, TFCC injury can be a cause of persistent ulnar pain after treatment of triquetral dorsal chip fracture. Arthroscopic partial TFCC resection can be considered to be a suitable treatment for such cases.

Clinical outcome of rearthrodesis in cases of non-union following four-corner fusion

PURPOSE

Four-corner fusion is a proven treatment option for degenerative arthritis of the wrist (SLAC/SNAC); however, in some cases, non-union occurs. The purpose of this study was to evaluate the clinical outcome of rearthrodesis in cases of non-union following four-corner fusion. Furthermore, the goal was to identify the cause of non-union and the location of pseudarthrosis within the fusion.

METHODS

Seven patients (5 males, 2 females) who experienced pseudarthrosis following a four-corner fusion procedure and subsequently elected a rearthrodesis procedure were clinically and radiologically examined. The average age was 58 years (range 48-71 years). Average follow-up after rearthrodesis was 27 months (range 4-60 months). All patients experienced persistent wrist pain and non-union was diagnosed via radiography or CT scan. Range of motion, grip strength, the Modified Mayo Wrist score, and the DASH score were evaluated. The level of pain was determined by using a visual analogue scale. Patients were also asked whether they were satisfied with the procedure and if they would elect it again.

RESULTS

In all patients, the rearthrodesis procedure led to proper bone consolidation, which was verified by radiological examination. Due to persistent wrist pain, one patient required additional procedures (denervation, wrist arthroscopy). In four cases, the location of pseudarthrosis occurred between the triquetrum and hamate. In three cases, the location of pseudoarthrosis was between the capitate and lunate and, additionally, between the triquetrum and hamate. The average DASH score value was 38 and the average Modified Mayo Wrist score was 66. Grip strength was reduced to 85 percent of the contralateral, unaffected side. Three patients indicated that they are dissatisfied with the results and would not elect the procedure again.

CONCLUSIONS

The most frequent location of pseudarthrosis was between the triquetrum and the hamate, which was caused by incomplete cartilage debridement. Proper bone consolidation could be attained by means of rearthrodesis in cases of non-union following four-corner fusion. However, clinical results remain only moderate.

Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome

The aim of the study was to evaluate the clinical outcome with subjective and neurophysiological parameters following partial medial epicondylectomy (pME) and to evaluate complications and recurrence rates. A retrospective analysis was performed in 29 patients (18 males and 11 females) with cubital tunnel syndrome (CuTS) who underwent pME. Mean time follow-up was 41.4 months. For subjective parameters, DASH (Disabilities of Arm, Shoulder and Hand), a self-created questionnaire about postoperative satisfaction and a visual pain scale (VAS) have been used. All patients were classified according to the Mc Gowan Classification (McG) and Wilson & Krout Classification (WKC). The patients were examined by nerve conduction velocity. Total mean of the DASH score was 24.8 points. In a questionnaire with integrated pain score (1-5), 96% of the patients declared a postoperative improvement, whereas 41.4% patients of the latter group were very contented with the results, 37.9% were contented, 17.2% were less contented and 3.4% were discontented. The VAS for evaluation of postoperative pain showed an average of 2.36 (0-5.9) out of 10. Of the patients, 68.0% were classified as grade I according to McG and 68.0% as excellent or good according to WKC. Motor nerve conduction velocity improved from 34.8 m/s preoperatively to 48.2 m/s postoperatively. One patient developed a haematoma and three patients (10.3%) had to be classified as recurrence. High postoperative rates of patient satisfaction and improved neurophysiological results could be achieved by pME.

Nerve fiber staining investigations in traumatic and degenerative disc lesions of the wrist

PURPOSE

Traumatic and degenerative disc lesions cause ulnar-sided wrist pain. To date, anatomical investigations of cadaver triangular fibrocartilage discs examining the innervation of the triangular fibrocartilage complex have found no evidence of nerve fibers in the healthy disc. In this study, we immunohistologically investigated biopsies from patients with either central traumatic or degenerative disc lesions, to determine the existence of nerve fibers. We hypothesized that an ingrowth of nerve fibers causes ulnar-sided wrist pain associated with traumatic and degenerative disc lesions.

METHODS

We included 32 patients with a traumatic Palmer 1A lesion and 17 patients with a degenerative Palmer 2C lesion in the study. We obtained a biopsy of each patient and stained the specimen with protein gene product 9.5 for nerve fiber detection.

RESULTS

There were no nerve fibers in either traumatic or degenerative disc lesions. In addition, the marginal areas of the biopsies showed no evidence of nerve fibers.

CONCLUSIONS

Traumatic and degenerative disc lesions show no ingrowth of nerve fibers.

Anterior interosseous nerve syndrome: retrospective analysis of 14 patients

INTRODUCTION

The anterior interosseous nerve (AIN) is a only motor nerve innervating the deep muscles of the forearm. Its compression is rare. We present a retrospective analysis of 14 patients with an AIN syndrome with a variety of clinical manifestations who underwent operative and conservative treatment.

PATIENTS AND METHODS

Fourteen patients (six female, eight male, mean age 48 ± 9 years) were included. In six patients, the right limb was affected, and in eight patients the left limb. Conservative treatment was started for every patient. If no signs of recovery appeared within 3 months, operative exploration was performed. Final assessment was performed between 2 and 9 years after the onset of paralysis (mean duration of follow-up 46 ± 11 months). Patients were examined clinically for return of power, range of motion, pinch and grip strengths. Also the disability of the arm, shoulder, and hand (DASH) score was calculated.

RESULTS

Seven of our 14 patients had incomplete AIN palsy with isolated total loss of function of flexor pollicis longus (FPL), five of FPL and flexor digitorum profundus (FDP)1 simultaneously, and two of FDP1. Weakness of FDP2 could be seen in four patients. Pronator teres was paralysed in two patients. Pain in the forearm was present in nine patients. Four patients had predisposing factors. Eight patients treated conservatively exhibited spontaneous recovery from their paralysis during 3-12 months after the onset. In six patients, the AIN was explored 12 weeks after the initial symptoms and released from compressing structures. Thirteen patients showed good limb function. In one patient with poor result a tendon transfer was necessary. The DASH score of patients treated conservatively and operatively presented no significant difference.

CONCLUSION

AIN syndrome can have different clinical manifestations. If no signs of spontaneous recovery appear within 12 weeks, operative treatment should be performed.

Objective outcome of partial medial epicondylectomy in cubital tunnel syndrome

AIM

Goal of the study was to evaluate the clinical outcome in cubital tunnel syndrome (CuTS) after partial medial epicondylectomy (pME) with objective parameters.

METHOD

A retrospective analysis was performed in 29 (18 male/11 female) patients with CuTS who underwent pME. Mean time follow-up was 41.4 months. Parameters assessed sensibility (two point discrimination (2PD) and Semmes Weinstein Monofilaments (SW)) of the fifth finger and grip and pinch strength. In addition, elbow range of motion, elbow instability, medial elbow pain, Froment sign and Tinel`s sign were evaluated.

RESULTS

Postoperative static 2PD of the fifth finger was 12.6 mm. SW values on the operated side (mean 3.58; 2.44-6.65) were comparable to the non-operated side (mean 3.28; 2.44-4.93). Tinel's sign over the ulnar sulcus was positive in 13 cases preoperative and in 16 cases postoperatively. Range of motion of the elbow joint achieved normal values in flexion/extension and pronation/supination with no significant difference in comparison to the non-operated side. Froment sign was positive in 2 cases, negative in 23 cases. Grip strength averaged 48.1 kg in man versus 24.4 kg in women. Pinch strength was 8.6 versus 5.3 kg. Grip strength on the operated side reached up to 91.0% values of the opposite arm.

CONCLUSION

Good postoperative objective results were reached by pME. pME is an adequate treatment option in CuTS.

Expression of TRAIL and death receptor DR4 in Palmer type 2 TFCC lesions

INTRODUCTION

Degenerative articular disc perforations of the triangular fibrocartilage (TFC) of the wrist are characterized by fibrocartilage cell loss and are often associated with ulna-plus situations. Apoptosis has been found to play a crucial role in fibrocartilage cell loss, however, the molecular mechanism and mediators are still poorly understood.

AIM

The purpose of this study was to identify receptors to apoptosis in degenerative disc lesions.

PATIENTS

Included in the study were 17 patients with degenerative articular disc tears of the TFC (Palmer type 2C). Following arthroscopic debridement of the TFC, histological sections were examined to assess the presence of apoptosis. Apoptosis was determined using TRAIL and death receptor DR4 agonists for immunohistochemical analyses. The number of cells positive for apoptosis was then correlated with ulna length.

RESULTS

Cells positive for TRAIL and DR4 were found in all specimens. The number of cells positive for TRAIL was significantly increased in specimens of patients with an ulna positive variance (P = 0.040). However, DR4 was not significantly increased in ulna plus (P > 0.05). Both, TRAIL and DR4 positive cells were found to be evenly distributed throughout each specimen. There was no accumulation of any type of cells in any particular zone of the biopsies.

CONCLUSION

This is the first study that shows that TFCC cells express TRAIL and DR4, which suggests that apoptosis, as well as, mechanical trauma are involved in the development of disc perforation. The TRAIL/DR4 receptor system is a molecular mediator of apoptosis induction in TFC cells and therefore plays a role in cell loss in degenerative disc lesions.