Arthroscopic Trans-osseous Suture of Peripheral Triangular Fibrocartilage Complex Tear

A Modified Arthroscopic Ulnar Tunnel Technique for Combined Foveal and Capsular (All-Inside) Fixation of Triangular Fibrocartilage Complex Injury

Background  Traumatic disruption of the triangular fibrocartilage complex (TFCC) is commonly present in various wrist traumas. A variation of surgical techniques is previously developed for different injury patterns. To our knowledge, only a few studies have investigated the fixation of combined foveal and capsular TFCC injuries using the ulnar tunnel technique. Purpose  This prospective cohort study of 21 patients aimed to evaluate the clinical and patient-reported outcome at 2 years of follow-up after arthroscopic TFCC of combined, foveal, and capsular reattachment by modified ulnar tunnel technique. Methods  Pain, grip strength, wrist motion, inclusive rotation, and patient-reported outcomes were assessed pre- and postoperatively at 2 years of follow-up. Results  No complications occurred preoperatively. Pain and patient-reported outcomes improved significantly ( p  < 0.0001 and 0.004). Grip strength improved, but not significantly ( p  = 0.088). The range of motion remained unchanged. All the patients achieved full stability of the distal radioulnar joint. Two patients sustained a new TFCC injury due to a wrist trauma and underwent a reoperation successfully. Two patients experienced complications: one patient experienced tenderness caused by cyst occurrence after PushLock ankers and the second had subluxation of the extensor carpi ulnaris tendon subsheet. Both patients were successfully treated and reoperated on with curettage of the cyst, and reconstruction of the extensor carpi ulnaris retinaculum. All the patients ended with good or excellent satisfaction scores. Conclusion  The ulnar tunnel technique for combined foveal and capsular injuries shows promising short-term follow-up results and high satisfaction scores in the patients. Level of Evidence  II (Prospective Corhorte).

Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review

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.

Advances in the Repair of Palmer type IB TFCC Injuries With Wrist Arthroscopy

The triangular fibrocartilage complex (TFCC) is essential for maintaining wrist stability. Injury-caused pain is the primary cause of ulnar wrist pain. The TFCC injury refractory to conservative treatment requires further surgical treatment, and because Palmer type IB tears belong to peripheral injuries due to their proximity to the blood supply area, arthroscopic suture repair has become the preferred surgical method for TFCC injury repair, exhibiting strong healing ability. This study reviewed the anatomy of TFCC, injury classification, and advances in arthroscopic suturing for treating Palmer type IB.

Foveal Triangular Fibrocartilage Complex Tear Repair with Nonabsorbent Suture Tape

PURPOSE

Arthroscopic repair is performed for fovea injuries of the triangular fibrocartilage complex (TFCC) when instability of the distal radioulnar joint results in pain, decreased grip strength, and mechanical symptoms. During TFCC repair, reconstruction of its attachment to the fovea is important. Nonabsorbent suture tapes have gained attention for ligament repair in the trapeziometacarpal joint, scapholunate ligament, and thumb metacarpophalangeal ligament. However, there are no reports of TFCC repair using suture tapes. We evaluated the early postoperative results of this approach.

METHODS

Participants underwent arthroscopic suture tape repair of foveal TFCC tears and were observed for more than 1 year. All repairs were performed using suture tapes and an outside-in technique with a bone tunnel from the ulnar shaft to the fovea. The postoperative complications, postoperative wrist range of motion, grip strength, and the Modified Mayo Score were evaluated.

RESULTS

Arthroscopic repair with a suture tape was performed for 20 hands using the outside-in technique. The ranges of motion for the operated and nonoperated hands were comparable 1 year after surgery (pronation, 84° ± 4°; supination, 83° ± 4°). The mean grip strength improved from 65% ± 13% before surgery to 89% ± 9% after a year. The mean Modified Mayo Score improved from 58 ± 11 before surgery to 91 ± 8 after a year. Postoperative complications included abnormal sensation of the dorsal ulnar side in 2 hands.

CONCLUSIONS

After using a suture tape to attach the TFCC to the fovea, satisfactory function was achieved in the early postoperative period with grip strength restoration. For the repair of foveal TFCC tears, attachment to the ulnar fovea is important, and repair by a suture tape may be useful.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A modified arthroscopic ulnar tunnel technique for foveal triangular fibrocartilage complex injury

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.

Arthroscopic transosseous foveal footprint repair of the triangular fibrocartilage complex

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.

Arthroscopic one-tunnel transosseous reconstruction of chronic triangular fibrocartilage complex foveal tears: outcomes in 12 patients

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.

Postoperative immobilization using a short-arm cast in the semisupination position is appropriate after arthroscopic triangular fibrocartilage complex foveal repair

AIMS

The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair.

METHODS

A total of 40 healthy right-handed volunteers were recruited. Active pronation and supination of the forearm were measured in each subject using a goniometer. In the retrospective clinical study, 40 patients who underwent arthroscopic foveal repair were included. The wrist was immobilized postoperatively using a SAC in the semisupination position (approximately 45°) in 16 patients and a LAC in 24. Clinical outcomes were assessed using grip strength and patient-reported outcomes. The degree of disability caused by cast immobilization was also evaluated when the cast was removed.

RESULTS

Supination was significantly more restricted with LACs than with SACs in the semisupination position in male and female patients (p < 0.001 for both). However, pronation was significantly more restricted with SACs in the semisupination position than with LACs in female patients (p = 0.003) and was not significantly different in male patients (p = 0.090). In the clinical study, both groups showed improvement in all parameters with significant differences in grip strength, visual analogue scale scores for pain, modified Mayo Wrist Score, the Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE) score. No significant postoperative differences were noted between LACs and SACs in the semisupination position. However, the disability caused by immobilization in a cast was significantly higher in patients who had a LAC on the dominant hand (p < 0.001).

CONCLUSION

We found that a SAC in the semisupination position is as effective as a LAC in restricting pronation of the forearm. In addition, postoperative immobilization with a SAC in the semisupination position resulted in comparable pain scores and functional outcomes to immobilization with a LAC after TFCC foveal repair, with less restriction of daily activities. Therefore, we recommend that surgeons consider using a SAC in the semisupination position for postoperative immobilization following TFCC foveal repair for dorsal instability of the distal radioulnar joint. Cite this article: Bone Joint J 2022;104-B(2):249-256.

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.

Arthroscopic Transosseous Repair of Foveal Tears of the Triangular Fibrocartilage Complex: A Systematic Review of Clinical Outcomes

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.

Arthroscopic ligament-specific repair for triangular fibrocartilage complex foveal avulsions: a minimum 2-year follow-up study

This study reports the arthroscopic ligament-specific repair of the triangular fibrocartilage complex (TFCC) that anatomically restores both the volar and dorsal radioulnar ligaments into their individual foveal footprints. Twenty-five patients underwent arthroscopic ligament-specific repair with clinical and radiological diagnoses of TFCC foveal avulsions. The mean age was 28 years (range 14-47) and the mean follow-up was 31 months (range 24-47). Following arthroscopic assessment, 20 patients underwent double limb radioulnar ligament repairs and five had single limb repairs. At final follow-up, there were significant improvements in wrist flexion-extension, forearm pronation-supination and grip strength. There were also significant improvements in pain and patient-reported outcomes as assessed by the patient-rated wrist evaluation, Disabilities of the Arm, Shoulder and Hand score and modified Mayo wrist scores. Arthroscopic ligament-specific repair of the TFCC does not require specialist dedicated equipment or consumables and offers a viable method of treating these injuries.Level of evidence: IV.

Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review

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.

Prognostic Factors Affecting Clinical Outcomes of Arthroscopic Assisted Reduction and Volar Plating through Preservation of Pronator Quadratus for Intra-Articular Distal Radius Fracture

Background: This study aimed to evaluate the clinical and radiological outcomes following an arthroscopic-assisted reduction and volar plating (AR-VP) surgery through pronator quadratus (PQ) preservation for treating intra-articular distal radius fractures (IA-DRFs) and to assess prognostic factors that affect functional outcomes. Methods: Between March 2014 and February 2017, 54 patients who had intra-articular DRF and underwent AR-VP through the PQ preservation technique and completed 1-year follow-up were enrolled. Patients were divided into the satisfactory group (excellent and good results) and an unsatisfactory group (fair and poor results) based on the modified Mayo Wrist Scoring System (MMWS) scored at 1-year follow-up to determinate prognostic factors that affected clinical outcomes. Patients' demographics, clinical outcome measures (VAS, DASH, PRWE, etc.), and pre-and post-operative radiographic parameters were analyzed. Results: The outcomes according to MMWS were 10 excellent, 22 good, 14 fair, and 8 poor. A univariate analysis showed a significant difference between the groups (p < .05) for all radiographic parameters, sex, and the presence of an intra-articular comminution. In the multivariate analysis, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to uninjured wrist (> 20.1°) at trauma were considered as significant poor prognostic factors of functional outcome. Conclusions: AR-VP surgery through PQ preservation for intra-articular DRFs has reliable clinical and radiological outcomes. However, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to the uninjured wrist (> 20.1°) at initial injury were considered poor prognostic factors for AR-VP through PQ preservation for intra-articular DRF.

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.

Arthroscopic Ligament-specific Repair for Triangular Fibrocartilage Complex Foveal Avulsion: A Novel Technique

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.