Complex Tears Research Articles

Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries

The use of arthroscopy was evaluated in 47 patients who were treated for suspected triangular fibrocartilage complex (TFCC) tears, scapholunate (SL) tears, and/or lunotriquetral (LT) tears. Wrist arthroscopy was performed using traction and standard portals. Any TFCC tear found was debrided to a stable rim. SL and LT tears were debrided to bleeding bone. The range of follow-up was 1.5 to 50 months (average, 15.4 months). Patient grading was determined usin the Mayo Modified Wrist Score. For the 28 patients with TFCC tears, the results were excellent in 13, good in 8, fair in 2, and poor in 5. For the 23 patients with SL tears, the results were 11, 9, 1, and 2, respectively. Of the 5 patients with LT tears, 1 result was excellent, and 4 were poor. Workers compensation did not affect results. Arthroscopic debridement of SL and TFCC tears has proven effective. Debridement of LT tears has not been as successful. Based on our results, we feel that arthroscopic debridement of SL and TFCC tears is warranted. Arthroscopy 1998 Jul-Aug;14(5):479-83

ULNAR-SIDED WRIST PAIN IN ATHLETES

A previously unpublished report of seven professional athletes who were treated for ulnar-sided wrist pain is presented in this article. This report is followed by an introduction to the anatomy, examination, and imaging of the ulnar side of the wrist. Specific sources of ulnar-sided wrist pain, including triangulofibrocartilage complex tears, lunotriquetral instability, distal radioulnar joint pathology, extensor carpi ulnaris subluxation, calcific flexor carpi ulnaris tendinitis, and pisotriquetral arthritis are presented.

Triangular fibrocartilage injuries in pediatric and adolescent patients

This is a retrospective review of 29 posttraumatic pediatric and adolescent patients with surgically documented triangular fibrocartilage complex tears. All patients complained of ulnar wrist pain. Fifteen patients (52%) sustained distal radius fracture at the time of the original injury. Twenty-three (79%) of the triangular fibrocartilage complex tears were Palmer 1B lesions. There were 31A, 11C, and 21D lesions. All 1B, 1C, and 1D tears were repaired. Coexisting pathology was present in 25 patients (86%). This pathology included ulnar styloid nonunion, distal radioulnar joint instability, ulnocarpal impaction, distal radius deformity, and intercarpal ligament tears, which were treated by ulnar styloid nonunion excision, distal radioulnar joint stabilization, ulnar shortening, radius corrective osteotomy, and intercarpal ligament debridement, respectively. The length of the follow-up period averaged 21 months. Three patients were lost to follow-up. Outcomes were graded by a modification of the Mayo wrist score. Twenty-four patients (89%) had excellent results, 3 had good results.

The fate of meniscal tears after anterior cruciate ligament reconstruction.

To investigate the incidence of meniscal pathology and subsequent treatment at an index arthroscopically assisted reconstruction of acute ACL tears (<3 weeks after injury) and to determine the outcome of meniscal pathology. Cohort study with average postoperative follow-up of 40 months (range, 24-76 months). University-based sports medicine center. Series of 162 patients admitted between January 1989 and July 1993. Follow-up was obtained for 105 patients. Initial presence, location, and treatment of meniscal tears. Subsequent surgery performed and further investigation or surgery being planned. Approximately 40% of patients had meniscal pathology at the index procedure. Most tears were in the lateral meniscus (34 of 45). All posterolateral tears and most other small tears were left untreated (25 of 45). Partial meniscectomies were performed on 17 large, complex, or radial tears that were not amenable to meniscal resuturing. Three meniscal repairs were performed on large, unstable tears. Most patients achieved good functional results. Of the five patients who required late meniscal surgery, three had normal menisci at the index procedure. The other two were asymptomatic until experiencing a reinjury. Despite ACL reconstruction in the acute phase, only two patients required treatment for postoperative arthrofibrosis. Three patients required revision ACL reconstruction after return to full activities and experiencing reinjuries. Stable tears of both lateral and medial menisci remain asymptomatic at 2 to 6 years' follow-up if treated conservatively. Those requiring further surgery had de novo tears or tears that were asymptomatic before reinjury. Although repair may be of benefit for large flap or bucket-handle tears, it does not appear necessary for most tears and may increase the incidence of postoperative stiffness.

鏡視下ＴＦＣＣ部分切除術の治療成績

We have performed wrist arthroscopic treatment in 35 patients for ulnar wrist pain associated with Triangular Fibrocartilage Complex tears, since 1994.An arthroscopic partial resection was performed in 20 cases.The age at surgery ranged from 16 to 52 years (average 32.7 years).Follow-up averaged 9.8 months.Post-Arthoscopy diagnoses were Palmer I-A; 6 cases, I-D; 3 cases, II-C; 11 cases.In all cases with ulnar variant <+3mm, the results were evaluated as excellent and good, but in all cases with ulnar variant >+3mm, we were not able to achieve satisfactory results.

Diagnostic wrist arthroscopy

Wrist arthroscopy has become an essential tool for the hand and upper extremity surgeon. It is useful in diagnosing and/or staging a wide range of conditions of the wrist, including cartilage injury, early arthritis, ligament injury, and triangular fibrocartilage complex tears. It can be of great benefit in evaluating wrist pain of unclear cause when imaging studies fail to elucidate the disease. In the hands of an experienced arthroscopist, it can be a more accurate diagnostic tool than studies such as magnetic resonance imaging or arthrography. The rate of complications is very low if proper attention is paid to details. Familiarity with the equipment, thorough knowledge of the anatomy, and development of a systematic approach are all critically essential for a surgeon performing arthroscopy of the wrist. The surgeon must also know when arthroscopy does not provide sufficient access to the wrist and an arthrotomy should be performed.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears

The functional outcome after surgery was determined in 21 patients an average of 29 months (range, 24-52 months) after surgery to evaluate the efficacy of arthroscopic repair of triangular fibrocartilage complex (TFCC) tears and ulnar shortening. All of the patients had reparable lesions of the TFCC treated after a delay of more than 6 months from the time of injury. The patients' average age was 32 years and all patients had wrist pain limiting them from work and/or sports prior to surgery. After surgery, there was a significant relief of pain (p < .01). Grip strength and range of motion averaged 83% +/- 18% and 81% +/- 16%, respectively, of that of the uninjured side. At follow-up evaluation, 14 patients with repairs underwent follow-up studies; the TFCC was noted to be intact in 12 patients.

Radiochemical studies on contact lens soilation. I. Lens uptake of 14C-lysozyme from simple and complex artificial tear solutions.

A systematic study has been made of the uptake of lysozyme by various contact lens materials. Lens uptake of 14C-methylated lysozyme was assessed using simple to complex artificial tear solutions. The data reflect prominent uptake by Group IV (ionic, high-water-content) hydrogel lenses, consistent with the literature. This includes protein on the lens surface and in the lens matrix, the former being estimated at about 33% of the total deposit for the DuraSoft 3 lenses used. Uptake appears to be contingent upon the nature of the lens material, the composition of the deposit model used, and the duration of lens exposure to the artificial tear solution.

Arthroscopic Repairs of Triangular Fibrocartilage Complex Tears

Technical advancements in arthroscopic wrist procedures have improved our knowledge of normal and abnormal intraarticular wrist function. Triangular fibrocartilage complex (TFCC) tears from trauma injuries are a common source of ulnar-sided wrist pain. Fortunately, the TFCC is a structure that can be evaluated and treated arthroscopically with results that are comparable to open surgical procedures. Successful arthroscopic repairs of TFCC tears depend on a coordinated team effort between perioperative nurses, orthopedic surgeons, nurse practitioners, and occupational hand therapists, as well as cooperation from patients and family members. This article reviews the anatomy and physiology of the TFCC, the biomechanics of the wrist and mechanisms of injury, and arthroscopic repairs of TFCC tears.

Radiochemical studies on contact lens soilation. I. Lens uptake of 14C‐lysozyme from simple and complex artificial tear solutions

A systematic study has been made of the uptake of lysozyme by various contact lens materials. Lens uptake of 14C-methylated lysozyme was assessed using simple to complex artificial tear solutions. The data reflect prominent uptake by Group IV (ionic, high-water-content) hydrogel lenses, consistent with the literature. This includes protein on the lens surface and in the lens matrix, the former being estimated at about 33% of the total deposit for the DuraSoft 3 lenses used. Uptake appears to be contingent upon the nature of the lens material, the composition of the deposit model used, and the duration of lens exposure to the artificial tear solution. © 1997 John Wiley & Sons, Inc.

Concomitant meniscal and articular cartilage lesions in the femorotibial joint.

The frequency of concomitant meniscal and articular cartilage lesions in the femorotibial joint was analyzed in a retrospective study of 1740 knee joints examined arthroscopically with the objective of determining possible correlations between the two knee joint abnormalities. Articular cartilage lesions were found in 81.4% (N = 1416) of femorotibial joints examined and meniscal derangements were noted in 72.8% (N = 1268). In the medial compartment, concomitance was noted in 76.3% (821 of 1076) on the femoral condyles and in 48.6% (523 of 1076) on the tibial plateau. In the lateral compartment, 43.1% (212 of 492) of the knees with deranged menisci had femoral and 55.1% (271 of 492) had tibial articular lesions. Medial meniscal lesions were more frequently associated with femoral and tibial chondral degeneration than lateral meniscal derangements (P < 0.001). Longitudinal, bucket-handle, and complex tears of the medial meniscus were significantly more often associated with articular cartilage damage than horizontal cleavage, flap, or radial tears. Degeneration of the meniscus was highly correlated with chondral destruction in both compartments. No cause-and-effect relationship could be established, but practical implications of these findings are discussed.

Injury of the posterior ligament complex in patients with acute spinal trauma: evaluation by MR imaging.

We undertook this study to use MR imaging to determine the frequency of injury to the posterior ligament complex of the thoracolumbar spine in patients who have undergone acute thoracolumbar trauma. Sixty-eight patients with varying severity of thoracolumbar trauma were examined prospectively. The majority of injuries were related to motor vehicle accidents. The second most common cause was falls. Patients were examined with plain radiography and MR imaging. In addition to conventional MR imaging sequences consisting of T1-weighted and fast spin-echo T2-weighted sagittal and axial images, a fat-suppressed T2-weighted sagittal sequence was performed. The findings were correlated with surgery in six cases and with follow-up clinical examination that included physical examination and conventional anteroposterior and lateral radiographs. Posterior ligament complex injury was detected in 53% (n = 36) of all patients. Such injury was most common in patients with flexion-distraction (n = 15) and patients with dislocation fracture (n = 4). Of the patients with dislocation fracture, all had posterior ligament complex injury. Of the 24 patients with burst fractures, posterior ligament complex tear occurred in 42% (n = 10). Of the 23 patients with compression fractures, 26% (n = 6) had posterior ligament complex tear. Injury to the interspinous ligaments occurred with decreasing frequency in patients with injury to the supraspinous ligament, flaval ligaments, posterior longitudinal ligament, and anterior longitudinal ligament. Surgical findings correlated with MR imaging in all six patients who underwent surgery. Injury to the posterior ligament complex, which is often encountered in patients with burst and compression fractures, can be reliably revealed by MR imaging.

Etiology and pathophysiology of tendon ruptures in sports.

Of all spontaneous tendon ruptures, complete Achilles tendon tears are most closely associated with sports activities (1-3). Schönbauer (3) reported that 75% of all ruptures of the Achilles tendon are related to sports. In Plecko & Passl (2) the number was 60%. In our material of 430 cases, the number of sports-related Achilles ruptures was very similar (62%), while only 2% of ruptures of other tendons were sports-related (P < 0.001) (1). Also, the majority of Achilles reruptures occurred in sports. The ruptures occurred most often in soccer (34%), track and field (16%) and basketball (14%). The distribution of Achilles ruptures according to different sports varies considerably from country to country, according to the national sport traditions. For example, in northern and middle Europe, soccer, tennis, track and field, indoor ball games, downhill skiing, and gymnastics are the most common; and in North America, football, basketball, baseball, tennis and downhill skiing dominate the statistics (1, 2, 4). In sports, some Achilles ruptures are not spontaneous or degeneration-induced but may occur as a consequence of the remarkably high forces that are involved in the performance (2). Ruptures in the high jump or triple jump are good examples. In such cases, failure in the neuromuscular protective mechanisms due to fatigue or disturbed co-ordination can frequently be found. The spontaneous complete rupture of the supraspinatus tendon of the rotator cuff does not occur very frequently in sports. Those sports that include high-energy throwing movements, such as American and Finnish baseball, American football, rugby and discuss and javelin throwing, may, however, produce this injury. Partial tears and inflammations of the rotator cuff complex are much more frequent in throwing sports. The complete rupture of the proximal long head of the biceps brachii tendon is rare among competitive and recreational athletes. In our material, under 2% of these ruptures were associated with sports activities (5). The rupture (avulsion) of the distal tendon of the biceps muscle is rare. In sports, gymnastics, body building and weight lifting have been said to be able to produce this injury (6). In general, complete ruptures of the quadriceps tendon and the patellar tendon occur most often in older individuals. In our study, the mean age of these patients was 65 years (5). However, these injuries do also occur in younger age groups, especially in athletes. In athletes, the rupture most frequently occurs in high-power sports events, such as high jump, basketball and weight lifting, at the age of 15-30 years. A chronic-patellar apicitis (jumper's knee) may predispose rupture of the tendon (7). As is the case with the rotator cuff complex, overuse inflammation and partial tears of the quadriceps and patellar tendons are one of the most characteristic athletic injuries. Complete spontaneous ruptures of other tendons in sports are rare, although the literature does provide case studies from almost every tendon the human body possesses (8-18).

Isolated tears of the triangular fibrocartilage: Management by early arthroscopic repair

To evaluate the efficacy of arthroscopic repair of the triangular fibrocartilage complex (TFCC) tears treated within 4 months after injury, functional outcome after repair was determined following arthroscopic repair in 24 patients. The patients' average age was 31 years (range, 22-38 years); the average follow-up period was 34 months (range, 26-48 months). All patients had wrist pain limiting their participation in work prior to surgery. Patients with central attrition tears identified by arthroscopy were excluded from the study. Twenty-three patients had a preoperative arthrogram. Twelve of the patients with positive arthrogram findings had an avulsion of the TFCC from the sigmoid notch (Palmer type 1D tears). Of the eleven patients with negative arthrograms, 10 had ulnar tears in capsular attachments of the TFCC. The ulna variance averaged 0.2 mm +/- 0.6 mm. Separate arthroscopic techniques were developed for reattaching the TFCC to the radius (nine patients) versus to the peripheral capsule on the volar or ulnar side of the wrist (eight patients). Postoperatively, there was a significant relief of pain (p < .01). Postoperative range of motion averaged 89% +/- 9% SD of the contralateral side, and grip strength averaged 85% +/- 20% SD of the contralateral side. Thirteen of the 19 patients returning to work did so in their original jobs.

Magnetic resonance imaging of thehand and wrist

The application of magnetic resonance imaging (MRI) to the hand and wrist has lagged behind its use in larger joints. Recent advances in hardware and software technology have allowed faster imaging with excellent anatomic resolution. After routine radiography, MRI is the imaging procedure of choice for evaluation of chronic wrist pain. The most common indications for MRI within the hand and wrist include scapholunate-lunate ligament tears, triangular fibrocartilage complex (TFCC) tears, avascular necrosis, and soft tissue masses. MRI may occasionally help evaluate tendon abnormalities, atypical or postoperative recurrent carpal tunnel syndrome, and complications of inflammatory arthritides. Future applications of MRI will likely include improved anatomic imaging of smaller structures such as the lunatotriquetral ligament and the extrinsic ligaments, as well as MR angiography (MRA).

Spectrum of acute dissection of the ascending aorta: A transesophageal echocardiographic study

Transesophageal echocardiography is an accurate tool for the immediate diagnosis of acute aortic dissection. In addition to establishing the diagnosis of dissection, transesophageal echocardiography provides determination of its extent and detection of complications. The purpose of this study was to delineate the full spectrum of abnormalities present in acute dissection of the ascending aorta as assessed by transesophageal echocardiography. Forty consecutive patients with acute ascending aortic dissection were evaluated. Specific attention was paid to complications of aortic valve insufficiency, pericardial effusion, and left ventricular wall motion abnormalities. The aortic arch and the descending aorta were also evaluated for involvement. Quantitative data included measurement of the aorta at the anulus, sinuses, and tubular portion, as well as the proximal and distal descending aortas. An intimal flap was identified in all patients. This was a simple linear tear in 22 patients (55%) and circumferential in eight (20%). A complex tear was noted in 10 patients (25%). The majority of patients ( n = 30; 75%) had extension of the dissection into the descending thoracic aorta. At least one communication between the true and false lumens (“entrance point”) was identified in 31 patients (78%). Pericardial effusions were noted in 19 patients (48%), only two of whom had a moderate-size effusion. Moderate or severe aortic insufficiency was seen in 18 patients (45%) and regional wall motion abnormalities in six patients. We conclude that acute dissection of the ascending aorta results in a complex or convoluted flap rather than a simple linear tear in many patients. The complication of clinically significant pericardial effusion was rare. Aortic insufficiency is common and can be attributed to multiple mechanisms.

MENISCAL REPAIR: Where Do We Go from Here?

In summary, it has been the task of this article to try to forecast the future of meniscal surgery over the next decade. As we enter the twenty-first century, it becomes evident that a combination approach will be the most likely procedure. The code phrase will be, "Save as much meniscus as possible." The authors predict that accomplishing this objective will involve the use of adhesive materials, possibly autologous but more probably exogenous, supported by the insertion of a collagenous type material, which will serve as a scaffolding for the ingrowth of fibrocartilage, and the healing will be stimulated by hormonal methods. Whether this occurs through recombinant DNA techniques or better methods of precipitation remains an issue. Dose-specific mitogens and chemotactic agents will be placed in the area of injury to potentiate the vascular fibrous response of the host tissue. With earlier and more exuberant fibrous response and initial tissue adhesion from the fibrin adhesive, better stability will be established to allow for primary healing of meniscal tissues. This procedure will work well for longitudinal tears of the meniscus. A dilemma arises with more complex tears of the meniscus, however. Previously irreparable tears may be conducive to resection then replacement with cultured autologous fibrochondrocytes, either in a gel-type form or on scaffolds made of collagen or biodegradable materials. These scaffold/fibrochondrocyte replacements may be contoured to the defect present and bonded tightly with the fibrin adhesives previously discussed. Again, growth factors would be needed for ultimate success as the fibrochondrocytes mature into the appropriate morphologic subpopulations and begin to turn over their own extracellular matrix. The patient would have a neomeniscal autologous transplant with normal host cell turnover of matrix. A brave new era lies ahead for meniscal repair, and the journey promises to be a most exciting one.

Technical Considerations In The Management Of Complex Meniscus Tears

Meniscal repair continues to be an important procedure in patients with meniscal tears. The orthopedic literature has recommended excision of complex tears or tears that are located in the central avascular region. For the past 13 years, the authors have repaired all meniscal tears that can be reduced anatomically and that have healthy tissue that will support the multiple sutures required for a stable repair, regardless of tear pattern or location. Correct patient selection criteria continue to be important. In all cases, the risks of complications and retear must be considered carefully and judged against the potential benefits of repair. A postoperative rehabilitation program that allows early range of motion, and progression of weight bearing is not detrimental to the healing process if the repair is stable. Close postoperative follow-up examinations are necessary to determine the incidence of meniscal symptoms; however, the absence of joint line pain, catching, locking, or effusion does not guarantee complete healing of the tear. Follow-up arthroscopy is currently the most accurate method to determine if complete or partial healing has occurred.

Arthroscopic repair of radial-sided triangular fibrocartilage complex tears

Treatment of triangular fibrocartilage complex (TFCC) tears is receiving considerable attention. Repair of peripheral tears of the TFCC has been recommended to restore the important functions of stability and load-bearing. Techniques for the reattachment of the periphery of the TFCC are evolving. Previous reports have mainly dealt with ulnar-sided (Palmer Class I-B) repairs. This report describes an arthroscopic technique for repair of radial-sided (Palmer Class I-D) TFCC tears. The procedure utilizes arthroscopic visualization with direct reattachment of the radial edge of the horizontal disk of the TFCC into the sigmoid notch of the distal radius. Fixation is achieved using sutures driven through the distal radius using long straight meniscal repair needles. Early clinical results following arthroscopic reattachment of radial-sided TFCC tears using this technique have been favorable. The technique is presented as an alternative method for repair of these lesions.

Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement

In order to determine indications for arthroscopic debridement and the management of triangular fibrocartilage complex (TFCC) tears, we reviewed 16 wrists retrospectively. The mean patient age was 30 years, with a range of 20 to 53 years. The follow-up period averaged 35 months. Two groups were identified: post-traumatic tears (n = 11) and degenerative tears (n = 5). The results of arthroscopic debridement were compared and analyzed based on the preoperative and postoperative evaluation of pain, range of motion, grip strength, return to work, patient acceptance, and complications. Failures were further evaluated to determine identifiable lesions or anatomic defects associated with poor results. Patients with positive ulnar variance and lunotriquentral interosseous ligament tears had a poor clinical outcome. Good results correlated with grip strength; all patients with post-traumatic TFCC tears had excellent results, while those with degenerative TFCC tears did poorly.