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

Postoperative Benefits of Soft Tissue Wrist Arthroscopy: Retro- and Prospective Analyses of Outcome Measures

Background: Elective soft-tissue-only wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist pain. A number of pathologies can be treated arthroscopically, with the aim of pain reduction and improved wrist mobility. A postinterventional evaluation of the treatment using objective and patient-reported outcome measures (PROMs) allows for an evidence-based statement about the benefits of soft-tissue-only wrist arthroscopy. Methods: A dual-center study combining retro- and prospective clinical analyses of patient outcomes after soft-tissue-only wrist arthroscopies was performed. The data were collected at two hospitals with departments specializing in hand surgery. The outcome was measured by assessing the range of motion of the wrist and its manual strength, as well as PROMs, including Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: A total of 154 soft interventions met the study criteria and could be included. Seven months after the elective soft-tissue-only wrist arthroscopies, mobility improved significantly for active extension and flexion, as well as the ulnar and radial abduction of the wrist. The grip strength also improved significantly, by an average of 6 kg, during this period. The DASH score improved significantly, from 35 points to 14 points. Additionally, wrist pain at rest was reduced significantly. Conclusions: After elective soft-tissue-only wrist arthroscopy, patients showed an overall functional improvement in their wrist, with a significant reduction in pain and improvement of mobility and grip strength. This study emphasizes the importance of wrist arthroscopy as a successful treatment option for soft tissue pathologies of the wrist.

Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex

Aims

The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes.

Methods

A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes.

Results

A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations.

Conclusion

Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment.

Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review

OBJECTIVE

To evaluate patients' ability to return to preinjury activity level after arthroscopically assisted triangular fibrocartilage complex (TFCC) repair.

DATA SOURCES

The PubMed electronic library was systematically searched from inception to August 2021 for any eligible articles using a combination of the phrases "TFCC," "return to sport," "return to work," and "athlete."

RESULTS

Studies that evaluated patients who had undergone arthroscopic repair of isolated TFCC injury and reported objective or patient-reported outcome measures were included. Fifteen studies representing 478 patients fulfilled the inclusion criteria. An average of 84% of patients were able to fully return to their previous work or sport activities. Most studies reported that range of motion (ROM) and grip strength (GS) both returned to >90% of the contralateral side, and every study that evaluated pain levels found a significant reduction in pain postoperatively. Mayo Modified Wrist Score was reported as excellent or good in 83% of patients, and the average Disabilities of the Arm, Shoulder, and Hand score was 13.8 postoperatively.

CONCLUSION

Patients were able to return to their previous work or sport activities at a high rate after TFCC repair, even those participating in more strenuous activities. Measurable functional outcomes of ROM and GS were also reliably restored to near preinjury levels. Patient-reported outcomes of pain and disability were similarly improved after TFCC repair. Current literature has established the long-term success of TFCC repair but is lacking in evaluation of the time points at which patients can expect functional status to be restored.

Predictors of Secondary Ulnar Shortening and Reoperation After Arthroscopic TFCC Debridement

BACKGROUND

Predicting which patients will do well with arthroscopic triangular fibrocartilage complex (TFCC) debridement alone or which patients may benefit from arthroscopic debridement and ulnar shortening at the same time can be challenging. In this retrospective cohort study, we aimed to assess the rate and type of complications and reoperations after arthroscopic TFCC debridement. Furthermore, we aimed to identify factors associated with reoperation and specifically ulnar shortening osteotomy (USO) after this procedure.

METHODS

We included 163 patients who underwent arthroscopic TFCC debridement as a first surgery for treatment of their ulnar-sided wrist pain. Patient charts were manually reviewed, and ulnar variance was measured on preoperative posteroanterior radiographs of the wrist. Bivariate analysis and multivariable logistic regression analysis were performed to identify factors associated with reoperation. Additional subgroup analyses looking at USO after TFCC debridement were performed with Kaplan-Meier analysis and Cox regression survival analysis.

RESULTS

We found a complication rate of 14% and a reoperation rate of 19% (most common USO with 10%). Chondromalacia was independently associated with reoperation. Forty percent of patients with a positive ulnar variance later proceeded to USO. A hazard ratio of 1.8 per millimeter of ulnar variance was found.

CONCLUSIONS

Our data suggest that patients with a positive ulnar variance with frank chondral loss at the time of arthroscopic TFCC debridement may benefit from simultaneous USO.

Grip Strength Measurement for Outcome Assessment in Common Hand Surgeries

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

Postoperative Imaging of Ulnar Wrist Pain

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

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

Introduction: Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents. Materials and Methods: A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed. Results: The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7–19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation. Conclusion: Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment

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.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Evaluation of radiological instability signs in the distal radioulnar joint in children and adolescents with arthroscopically-verified TFCC tears

INTRODUCTION

Recent reports in the adult literature reported the use of standardized radiographic measurement techniques to determine distal radioulnar joint (DRUJ) instability. The aim of this study was to evaluate the efficacy and accuracy of (1) the MRI-based modified radioulnar ratio technique and (2) the pisoscaphoid (PiSca) and radioulnar (RaUl) distances in true lateral radiographs in children and adolescents with arthroscopically-verified TFCC tears.

MATERIALS AND METHODS

We retrospectively assessed lateral wrist radiographs and axial MRI sequences of 18 adolescent patients (22 wrists) who had arthroscopically-confirmed TFCC tears and compared them to similar imaging of a control group of 28 healthy patients (28 wrists). Three raters assessed the images twice in a 2-week interval. Intraclass correlation coefficients (ICCs), unifactorial ANOVA, and ROC analysis were performed with regards to the different radiographic variables.

RESULTS

The interrater ICCs were almost perfect for all measurements except RaUl1, which showed a substantial agreement (0.751) among the three observers. The intrarater ICCs were almost perfect when measuring PiSca and MRI, and substantial to almost perfect for RaUl. Pearson's correlation showed a moderate, positive correlation between PiSca and RaUl distances (r = 0.608; p < 0.001), and a moderate, negative correlation between RaUl distance and MRI shift (r = - 0.486; p = 0.010). When the three core groups (peripheral, central tear, controls) were compared to each other regarding the radiographic instability parameters, only the MRI shift revealed a statistically significant difference (p = 0.003). Comparisons revealed significant differences between patients and controls (p = 0.004) and peripheral tears vs. controls (p = 0.001 and p = 0.010). The ROC analysis revealed a significant AUC only for the MRI (AuC 0.787 and p = 0.002).

CONCLUSIONS

Children and adolescents with peripheral TFCC tears showed significantly increased instability parameters in MRI compared to controls. These measurement techniques are no replacement for a thorough clinical examination but may be helpful for indicating diagnostic wrist arthroscopy in ambiguous cases.

LEVEL OF EVIDENCE

Level III; Diagnostic.

Prognostic factors for the outcome of arthroscopic capsular repair of peripheral triangular fibrocartilage complex tears

BACKGROUND

Little information is available about prognostic factors of arthroscopic capsular repair for peripheral triangular fibrocartilage complex (TFCC) lesions. The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic capsular repair for peripheral TFCC tears.

METHODS

This study retrospectively enrolled 60 patients who were treated with arthroscopic outside-in capsular repair for peripheral TFCC tears. Functional survey, including pain numeric rating scale (NRS) on an ulnar provocation test, distal radio-ulnar joint (DRUJ) stress test, Disability of the Arm, Shoulder, and Hand (DASH) score, and satisfaction with treatment, was conducted at 12-month follow-up. Patients who were enthusiastic or satisfied comprised the satisfied group, and those who were noncommittal or disappointed the dissatisfied group. Demographic, clinical, and arthroscopic findings were compared between the satisfied and dissatisfied groups.

RESULTS

The mean pain NRS and DASH scores exhibited significant clinical improvement at the 12-month follow-up. Out of the total participants, 46 were satisfied and 14 were dissatisfied about the treatment, with significantly more female subjects in the dissatisfied group than in the satisfied one. The patients in the satisfied group had a shorter duration of symptoms, were more likely to have trauma history, and exhibited positive DRUJ stress test results compared to the dissatisfied group. There were no significant group differences in age, hand dominance, work level, and the extent of ulnar plus variance. Multivariable analysis revealed that female gender, a longer duration of symptoms, or negative DRUJ stress test results were associated with an increased disability after arthroscopic TFCC repair.

CONCLUSION

Female gender, a longer duration of symptom, and a negative DRUJ stress test are associated with a higher likelihood of treatment failure after arthroscopic outside-in capsular repair of peripheral TFCC tears.