Central Triangular Fibrocartilage Complex Research Articles

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

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. 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. 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. 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.

Arthrex Mini Tightrope Fixation for Chronic Distal Radioulnar Joint Instability.

Chronic distal radioulnar joint (DRUJ) instability is a complex clinical condition that is difficult to treat. Currently, there is no gold standard treatment. We present a novel technique using Arthrex Mini Tightrope for DRUJ stabilization. In this case series, a 1.6 mm K-wire was passed transversely through the distal ulna and radius. The Mini Tightrope was inserted into the end of the K-wire and pulled through the bone tunnels. Appropriate tension was achieved to stabilize the joint according to individual laxity comparable to the contralateral side. Five patients (3 males and 2 females) comprised this pilot series, with a mean age of 27.1 years. All sustained a traumatic injury at an average of 12.4 months before surgery (range: 5 to 32 mo). In addition, 3 patients had central triangular fibrocartilage complex tears treated with arthroscopy at the time of Mini Tightrope placement. While one patient was lost to follow-up after 7 weeks postoperative due to incarceration, 4 patients demonstrated coronal and sagittal stability in the context of DRUJ motion and a satisfactory range of motion. The mean time for the return to work for the two patients who were laborers or normal activity postoperatively was 5.2 weeks (range: 1 to 16.4 wk). Unrestricted activity was generally allowed 8 weeks postoperatively but varied by patient. The same 4 patients underwent hardware removal at an average of 31 weeks (range: 15 to 44 wk). Although this is only a pilot series, this suggests that temporary Mini Tightrope stabilization of the DRUJ may be a viable solution while upholding the benefits of minimally invasive surgery.

Structurally intact and functionally incompetent foveal triangular fibrocartilage complex injuries : an under-recognized spectrum of injury.

Injury to the triangular fibrocartilage complex (TFCC) may result in ulnar wrist pain with or without instability. One component of the TFCC, the radioulnar ligaments, serve as the primary soft-tissue stabilizer of the distal radioulnar joint (DRUJ). Tears or avulsions of its proximal, foveal attachment are thought to be associated with instability of the DRUJ, most noticed during loaded pronosupination. In the absence of detectable instability, injury of the foveal insertion of the radioulnar ligaments may be overlooked. While advanced imaging techniques such as MRI and radiocarpal arthroscopy are well-suited for diagnosing central and distal TFCC tears, partial and complete foveal tears without instability may be missed without a high degree of suspicion. While technically challenging, DRUJ arthroscopy provides the most accurate method of detecting foveal abnormalities. In this annotation the spectrum of foveal injuries is discussed and a modified classification scheme is proposed.Cite this article: Bone Joint J2023;105-B(1):5-10.

Foveal Triangular Fibrocartilage Complex Tears: Recognition of a Combined Tear Pattern

Triangular fibrocartilage complex (TFCC) injuries are categorized most commonly by the Palmer and the Atzei and Luchetti classifications. Combined tears are reported less frequently, and the classification of these tears is unclear. In this study, we present a series of patients with combined central disc and foveal TFCC tears that do not fit into either of these classifications. Seventeen patients from 2 institutions presented with a combined central and foveal TFCC tear, confirmed by wrist arthroscopy between September 2017 and December 2020. Patient demographics, injury mechanism, associated injuries, clinical findings, magnetic resonance imaging results, surgeon description of tears, and treatment rendered were evaluated. Patients were predominantly female (76%). Mean age was 40 years with a bimodal age distribution (7/17 patients <35 and 10/17 >45 years). Eleven patients (65%) sustained the injury from a fall. All had some degree of distal radioulnar joint (DRUJ) instability on clinical examination and almost half (8/17) had a history of a distal radius or ulnar styloid fracture during the initial injury. The foveal tear was confirmed by direct visual assessment and a positive hook test result; a suction test result commonly was positive as well. All patients underwent debridement of the central tear, and 16 of 17 underwent foveal TFCC repair with 1 having an irreparable tear. We present a series of patients with combined central disc and foveal TFCC tears, a pattern that does not fit current classification schemes. All patients exhibited some degree of instability of the DRUJ and almost half had a history of distal radius or ulnar styloid fracture. Identification of a central tear of the TFCC, together with even subtle DRUJ instability, should lead to consideration of a coexistent foveal tear. Diagnostic IV.

Retraction Note to: Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50years.

Retraction Note to: Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50years.

The Value of the Distal Radioulnar Joint Effusion in Diagnosing Triangular Fibrocartilage Complex Tears on Magnetic Resonance Imaging.

A retrospective study was conducted to evaluate the role of distal radioulnar joint (DRUJ) effusion in aiding the diagnostic accuracy of central triangular fibrocartilage complex (TFCC) tears on non-contrast MRI. 89 consecutive patients who had undergone wrist arthroscopy for ulna sided wrist pain in our unit were identified and their preoperative imaging reviewed. Two consultant musculoskeletal Radiologists independently reported the presence or absence of a DRUJ effusion and or a TFCC tear. The inter-observer variability was calculated using weighted Kappa tests. Two by two tables were constructed to calculate the sensitivity and specificity of reported TFCC tear or DRUJ effusion on MRI in correctly diagnosing central TFCC tears identified at arthroscopy. Sensitivity of MRI to report a TFCC tear was 0.56 and specificity was 0.79. Sensitivity increased to 0.89 if either a DRUJ effusion or TFCC tear were seen on MRI. When observed together, the presence of both a DRUJ effusion and a TFCC tear seen on the imaging lead to a sensitivity of 0.74 and PPV of 82% when compared to findings at arthroscopy. In the absence of both DRUJ effusion and TFCC tear, the specificity of MRI increased to 0.92. Agreement by the radiologists on the presence of DRUJ effusion was substantial (k value 0.67) and TFCC tear was moderate (k value 0.58). The presence of DRUJ effusion on MRI can further improve sensitivity of MRI in diagnosing central TFCC tears. The sensitivity of detecting a central TFCC tear on MRI scan when both a DRUJ effusion and a TFCC tear were seen (0.74) is comparable to rates demonstrated on MRA meta-analysis results (0.78). Furthermore, considering the absence of both a DRUJ effusion and TFCC tear seen on MRI is useful in excluding the presence of a TFCC tear at arthroscopy.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex.

The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions. A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done. Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred. Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance. Therapeutic IV.

Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist

IntroductionLigament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist. Materials & methodsAll patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA. ResultsThe gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively. Discussion & conclusionsDirect MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.

Direct wrist magnetic resonance arthrography in triangular fibrocartilage lesions

Objective The objective of this study was to assess the diagnostic accuracy of direct wrist magnetic resonance arthrography (MRA) compared with arthroscopy in the diagnosis of triangular fibrocartilage complex (TFCC) lesions. Patients and methods A total of 25 (12 men and 13 women) consecutive patients, in the age range from 16 to 49 years (mean age: 28 years) complaining of unexplained chronic wrist pain and suspected to have TFCC lesions were prospectively examined by direct MRA with arthroscopic correlation. Results Compared with arthroscopic results, the sensitivity, specificity, and accuracy of direct MRA for central TFCC lesions were 100% for all three and 100, 90.9, 96%, respectively, for peripheral lesions. Conclusion Direct MRA can diagnose TFCC lesions with very high sensitivity and specificity and can help in reducing arthroscopies for pure diagnostic purposes.

RETRACTED: Prognostic Factors of Arthroscopic Debridement for Central Triangular Fibrocartilage Complex Tears in Adults Younger Than 45 Years: A Retrospective Case Series Analysis

The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic debridement for central triangular fibrocartilage complex (TFCC) lesions in adults <45years of age. A total of 71 patients (mean age, 39years; range, 20-44years) who had been arthroscopically diagnosed with central TFCC tears were treated with arthroscopic debridement. Demographic, clinical, and arthroscopic findings were examined and analyzed. The response to treatment, including pain numeric rating scale on an ulnar provocation test; Disability of the Arm, Shoulder, and Hand score; and satisfaction with treatment, was assessed at 12-month follow-up. The mean pain numeric rating scale (6.6 ± 3.6 to 2.4 ± 2.0, P < .01) and Disability of the Arm, Shoulder, and Hand (59.3 ± 15.0 to 33.7 ± 14.1, P< .01) scores exhibited significant clinical improvement at 12-month follow-up. In terms of satisfaction, 43 patients (70.5%) were satisfied (enthusiastic or satisfied) and 18 (29.5%) were dissatisfied (noncommittal or disappointed). In the satisfied group, there were 24 flap and 19 wearing tears, whereas in the dissatisfied group, there were 4 flap and 14 wearing tears (P= .02). The extent of ulnar plus variance on preoperative radiographs also differed between the 2 groups (0.5 ± 1.2 vs 1.7 ± 1.1, P < .01). There were no significant differences in age, gender, hand dominance, or work level between the groups. After controlling for confounding variables, the wearing type tears (odds ratio, 3.4) and greater ulnar plus variance (odds ratio, 2.0) were associated with a higher likelihood of dissatisfaction after arthroscopic TFCC debridement. Although clinical outcome scores showed significant improvement after arthroscopic debridement for central TFCC tears, wearing type tears and greater ulnar plus variance were associated with dissatisfaction and poorer postoperative outcomes after the procedure. Level IV, case series.

Arthroscopic Management of Triangular Fibrocartilage Complex (TFCC) Injuries

Background: Triangular fibrocartilage complex (TFCC) injury is major cause of ulnar side wrist pain. It can lead to distal radio ulnar joint instability. Aim of the work: was to examine the efficacy of arthroscopic management of the TFCC injuries, and assess the functional outcome of this procedure. Patients and Methods: Twenty patients with torn TFCC underwent arthroscopic management. Five patients had central TFCC tears to which arthroscopic debridement was done. Five patients had superficial peripheral TFCC tears to which arthroscopic reattachment to the capsule was done. Ten patients had deep foveal TFCC tears with DRUJ instability to which arthroscopic assisted foveal reattachment by suture anchor was done. All patients were assessed before and after surgery (at follow-up) by Visual Analogue Scale (VAS) for pain, the Disability of the Arm, Shoulder and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), and the incidence of complications. Results: Twenty patients were available for follow-up at a mean of 12.9 months. VAS improved from a mean of 6 to a mean of 1.3 (p<0.001). The DASH score improved from a mean of 28.2 to a mean of 5.8 (P < 0.001). MMWS improved from a mean of 66.3 to a mean of 88.5 (p<0.001). Conclusion: Arthroscopic management of TFCC tears has shown to reach good results according with different TFCC lesions and improvement in pain and function. However, the current study is limited by absence of conservative or open control group for comparison and the relatively short follow-up period.

Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50years.

Few studies have addressed the prevalence of central triangular fibrocartilage complex (TFCC) tears or their risk factors for symptom development. The aim of this study was to determine the prevalence of radiographic central TFCC tears in both symptomatic and asymptomatic individuals, and evaluate clinical characteristics of symptomatic individuals. In this retrospective case control study, 221 patients younger than 50years who exhibited positive ulnocarpal provocation test and underwent MRI to identify abnormalities associated with TFCC were age- and sex-matched with 221 controls who had undergone hand or wrist MRI for tumorous lesions or pain in hand other than ulnar-sided wrist. Demographic and radiologic parameters including the degree of ulnar plus variance, the type of central TFCC lesions, the presence of ulna head or carpal bone enhancement, and cartilage degeneration of ulno-carpal or distal radio-ulnar joint were compared. Multivariable regression analysis was carried out to identify independent risk factors for symptom development in patients with central TFCC lesions. The prevalence of central TFCC lesions was 68/221 in symptomatic patients, which was not significantly different from that (51/221) in asymptomatic controls. Patients in the symptomatic group had significantly greater ulnar plus variance (1.6 vs. 0.7). They were more likely to have type 1A tears and bony enhancement in ulnar head or carpus on MR images. Multivariable logistic regression analysis revealed that youth, female gender, and presence of bony enhancement were significant risk factors for symptom development in central TFCC lesions. Based on the findings of this study, prevalence of central TFCC lesions detected on MRI in symptomatic patients seems to be similar to that in asymptomatic individuals. Younger age, female gender, and presence of bony enhancement on MR images seem to be risk factors for symptoms of central TFCC lesions.

Wrist Injury - Tae Kwon Do

HISTORY: An 18-year-old right-hand dominant male, nationally-ranked Tae Kwon Do competitor presented with a 4 year history of left wrist pain. Four years prior to presentation, he was kicked on the ulnar wrist while sparring. At that time, he had tenderness over the ulnar styloid and distal physis, no tenderness at the ulnar-carpal articulation, and full wrist range of motion. Wrist X-Rays were read by radiology as negative for fracture, but interpreted by the sports medicine team as a possible ulnar Salter- Harris I injury in addition to a wrist contusion. He returned to sport after three weeks of relative rest and use of a wrist brace. He presented to clinic four years later due to worsening symptoms that inhibited his level of competition in Tae Kwon Do. He had not sustained any further wrist injuries in the interim. There was increased pain with active range of motion and he felt an occasional click in his wrist and intermittent tingling in his fifth digit. PHYSICAL EXAMINATION: Left wrist exam demonstrated no gross deformity, swelling, erythema, or ecchymosis. The limb was neurovascularly intact. There was tenderness to palpation of the hook of the hamate and the triangular fibrocartilage complex. Full wrist and hand range of motion. Mild weakness noted in fifth digit flexion and wrist flexion; strength otherwise intact. Wrist extension with ulnar deviation reproduced the patient’s pain. There was increased dorsal instability of the ulnar styloid at the distal radioulnar joint (DRUJ) (positive piano key sign). DIFFERENTIAL DIAGNOSIS: 1. TFCC tear 2. Post-traumatic arthritis 3. Hook of the hamate fracture 4. Flexor carpi ulnaris strain 5. Ulnar neuropathy at the wrist TESTS AND RESULTS: MR arthrogram: There is contrast extension into the distal radioulnar joint indicating disruption of the triangular fibrocartilage complex (TFCC). The TFCC appears irregular and demonstrates intermediate signal. These findings were interpreted by the Sports Medicine team to represent concomitant central and peripheral TFCC tears. FINAL DIAGNOSIS: Central and peripheral TFCC tears TREATMENT AND OUTCOMES: After consultation with orthopedic surgery, the patient is currently scheduled for arthroscopic debridement of the central tear and repair the peripheral tear of his TFCC.

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

Injuries of the triangular fibrocartilage complex (TFCC) are of high clinical relevance; however, the clinical evidence for treatment is poor and long-term results are rarely published. The purpose of this study was to evaluate the clinical outcome of symptomatic central traumatic lesions of the TFCC (Palmer 1A) following arthroscopic debridement. Between 2007 and 2013, 87 patients were arthroscopically diagnosed with Palmer 1A lesion and accordingly treated with debridement. Follow-up was available for 43 patients. Activities of daily living (ADLs) were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Pain perception was evaluated with visual analogue scale (VAS 0-10). Grip strength and wrist motion were assessed with conventional techniques using a Jamar dynamometer and a goniometer. Patient satisfaction was assessed using a questionnaire at follow-up. Mean follow-up was 42.5months (range 5-70). The mean age of the patients (22 male and 21 female) at time of surgery was 41 ± 15.9years. No major complication occurred during surgery and follow-up. The DASH score (preoperatively 49.8 ± 19.3 vs. postoperatively 14.1 ± 17.9, p < 0.05) and pain perception (VAS: preoperatively 7.2 ± 2.0 vs. postoperatively 1.4 ± 1.6, p < 0.05) improved significantly. Grip strength was satisfactory after surgery (19.6 ± 13.1). Ulnar deviation improved significantly from 29.3 ± 10.4° to 35.6 ± 8.3° (p < 0.05) and wrist flexion improved from 53.8 ± 18.9° to 67.4 ± 12.9° (p < 0.05). Wrist extension, radial deviation, pronation and supination did not change significantly after surgery. Improved symptoms were reported by 41/43 (95.3%) patients and 40/43 (93%) patients would have had the same procedure again knowing the final outcome. Six of 43 patients (15%) had an ulnar plus variance. None of these needed ulnar shortening. Central traumatic TFCC lesions can safely be treated by arthroscopic debridement. We showed a sustained pain relief with significantly improved quality of life (DASH score) and wrist motion at follow-up. This resulted in a high patient satisfaction and acceptance of the procedure. Therapeutic, level IV.

The Effect of Axial Loading on Ulnar Variance.

Background Forearm rotation results in change in ulnar variance. Axial loading of the wrist is required to maintain daily activities. Change in ulnar variance during axial loading has not been investigated previously. Purpose To measure the change in ulnar variance on axially loaded wrists. Patients and Methods We examined 21 asymptomatic individuals and 24 patients with unilateral ulnar-sided wrist pain. All patients underwent standard neutral posteroanterior wrist radiographs without load and under axial loading on bilateral wrists. Axial loading was standardized at 18.1 kgf using an analog weight scale. A magnetic resonance (MR) arthrogram was obtained only in patients with ulnar-sided wrist pain. Beighton flexibility score was recorded on healthy volunteers. Change in ulnar variance between 0 and 18.1 kgf was compared for each wrist among all subjects. A correlation was sought between the change in ulnar variance, MR arthrogram findings, and physical examination. Results In individuals without wrist pain, on average, 0.4 mm increase in ulnar variance was measured between 0 and 18.1 kgf. There was no difference between the dominant and nondominant side. No correlation was found with increasing age. In contrast, patients with ulnar-sided wrist pain displayed an average increase of 0.8 mm in ulnar variance. Compared with the contralateral wrist, more than 1 mm increase in ulnar variance was correlated with intra-articular pathologies including dorsoulnar ligament disruption, central triangular fibrocartilage complex (TFCC) perforation, and foveal detachment. Conclusion Compared with contralateral side, more than 1 mm increase in ulnar variance is suggestive of longitudinal instability or TFCC pathology. Level of Evidence Level II, diagnostic.

Diagnostic accuracy of single-compartment magnetic resonance arthrography in detecting common causes of chronic wrist pain.

III.

Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy.

II.

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain.

Background: This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Methods: Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. Results: One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Conclusion: Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.

Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases.

Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two-center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5-year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar-sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.

Arthroscopic Wafer Procedure for Ulnar Impaction Syndrome

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.