Peripheral Triangular Fibrocartilage Complex Research Articles

Primary Arthroscopy-Assisted Foveal Repair of Triangular Fibrocartilage Complex Associated with Acute Distal Radius Fractures in Young Adults

Abstract Background In distal radius fractures (DRFs) occurring in nonosteoporotic age groups, it is known that triangular fibrocartilage complex (TFCC) injuries are frequently combined, with some experiencing persistent symptomatic instability. However, a gold standard treatment for these associated lesions has not yet been established. Purpose Our purpose was to investigate the outcomes of primary arthroscopy-assisted transosseous foveal repair of the TFCC associated with DRFs in young adults. Methods Fifteen patients aged <65 years who underwent open reduction and internal fixation for DRF and arthroscopy-assisted repair for foveal tear of the TFCC were included. Those patients were observed to have complete peripheral TFCC tear on preoperative wrist magnetic resonance imaging and intraoperative distal radioulnar joint (DRUJ) stability tests. This was confirmed with an arthroscopic examination. The transosseous technique was used to repair the TFCC after firm fixation of the DRF. The patients were immobilized with the long-arm splint in a neutral position for 2 weeks postoperatively and a removable short-arm splint was applied for another 2 weeks. DRUJ stability, grip strength, and patient-reported outcomes, including disabilities of the arm, shoulder, and hand (DASH) and Patient-Rated Wrist Evaluation scores, were evaluated as primary outcomes at 3, 6, and 12 months postoperatively. Results All patients showed a stable DRUJ throughout the follow-up period. The average grip strength ratio compared to the unaffected side was 69, 83, and 90% at 3, 6, and 12 months after surgery, respectively. The mean DASH score was 26.9, 18.4, and 6.7 at 3, 6, and 12 months postoperatively, respectively. Conclusion Primary arthroscopy-assisted transosseous foveal repair of the TFCC with internal fixation of the distal radius resulted in early recovery and good clinical outcomes in young patients. Level of evidence Therapeutic, level IV.

A Simple Surgical Technique for Arthroscopic Repair of Traumatic Radial-Side Peripheral TFCC Tear.

Conventionally, The Triangular Fibrocartilage Complex (TFCC) surgical procedures are complex in nature with open explorations and long hospital stays not to mention the added costs and the psychological stress for both the surgeon and the patient. Nowadays, surgical procedures are looked at in a different scope with the rapid progress of arthroscopic technology and equipment. To elaborate, here we introduce a simple surgical technique for arthroscopic repair of traumatic radial -side peripheral TFCC tear. In spite of the various surgical techniques found in the literature, we just used a k-wire and a couple of needles in order to repair Radial-sided peripheral TFCC tear. the simplicity of the current technique, adequate satisfaction and eliminating the use of a targeting device, is what sets this apart. For emphasis, this technique is less time consuming and is cost-effective with satisfactory result.

A new arthroscopic repair technique for triangular fibrocartilage complex using an intracapsular suture: an outside-in transfer all-inside repair

BackgroundArthroscopic repair is a promising, minimally invasive surgical technique for patients with Palmer type 1B peripheral triangular fibrocartilage complex (TFCC) tears. Although several arthroscopic techniques are effective for repairing Palmer type 1B TFCC tears, some shortcomings remain. So, we report an arthroscopic repair technique for the treatment of Palmer type 1B Atzei class 1 TFCC tears using an intracapsular suture: an outside-in transfer all-inside repair.MethodsA retrospective analysis of 38 Palmer type 1B TFCC injury patients admitted to our hospital were randomly divided into 2 groups. The group A was sutured from the outside to the inside, with a total of 21 cases; the group B was sutured with the new arthroscopic repair technique, with a total of 17 cases. Observe and compare the VAS scores and modified Mayo wrist function scores of all patients before 3, and 6 months after the operation and evaluate the incidence of thread knots in patients with different treatment methods. The methodology was performed an arthroscopic intracapsular suture using an outside-in transfer, all-inside repair technique, which is a modified method of the outside-in and all-inside technique using the needle of a 10-mL sterile syringe, for Palmer type 1B TFCC tears. A No. 2 polydioxanone suture was threaded through the needle and entered the wrist joint. Next, the needle was withdrawn carefully along the suture to the proximal tear ulnar surface of the TFCC and penetrated the TFCC, exiting the articular cavity surface of the ulnar side of the torn TFCC. Finally, arthroscopic knotting was performed.ResultsThis new treatment was as effective as the previously arthroscopic techniques and had the advantages of no additional incision and decreased risk of operation-related complications. The incidence of thread knots in the group A (28.57%) was significantly higher than that in the group B (0%), and the difference was statistically significant (P = 0.024). There was no significant difference in VAS score and modified Mayo wrist function scores between the two groups (P > 0.05).ConclusionsThe outside-in transfer, the all-inside repair technique is suitable for Palmer type 1B Atzei class 1 TFCC tears. We recommend this technique as a useful alternative to the conventional methods of repairing Palmer type 1B TFCC tears.

All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears

Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress. A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared. Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively). All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique. Therapeutic IV; retrospective comparative study.

Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case–control study

ObjectivesTo evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears.MethodsOne hundred thirty-three patients (age range 21–75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case–control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy.ResultsOn arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone.ConclusionsECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears.Key Points• ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears.• If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone.• If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

All-Arthroscopic Triangular Fibrocartilage Complex Ligamentoplasty: Technique and Results.

Objective The aim of the study is to describe the modified all-arthroscopic technique for triangular fibrocartilage complex (TFCC) ligamentoplasty in chronic injuries of the TFCC with distal radioulnar joint (DRUJ) instability, and to present the results obtained. Methods A prospective study was conducted including 11 consecutive patients with chronic TFCC injury with DRUJ instability who underwent an all-arthroscopic TFCC ligamentoplasty. During follow-up, the range of joint motion, grip strength, pain according to the visual analog scale (VAS), functional outcomes according to the Mayo Wrist Score (MWS), and the QuickDASH Score were measured, and any complications and necessary reinterventions were recorded Results We analyzed 11 patients with distal radioulnar ligament injury treated using the all-arthroscopic ligamentoplasty technique. Mean follow-up was 31.5 ± 4.4 (range 12-58) months. The technique presented achieved DRUJ stability in 100% of cases at 12 months. Grip strength and pain, showed a statistically significant improvement between the preoperative score and the two postoperative assessments. Functional assessment using the QuickDASH score and the MWS also improved significantly. Conclusion The all-arthroscopic technique for the reconstruction of irreparable peripheral TFCC tears is a reliable technique, intended not only to minimize the surgical trauma to reduce postoperative pain and to facilitate rehabilitation, but also to improve both the quality of the reconstruction and the functional outcome.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist

BackgroundIn wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC).MethodsEighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (rɸ).ResultsThe most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior–posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (rɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (rɸ = 0.172; p = 0.111).ConclusionsSince ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Retraction Note to: Prognostic factors for the outcome of arthroscopic capsular repair of peripheral triangular fibrocartilage complex tears.

Retraction Note to: Prognostic factors for the outcome of arthroscopic capsular repair of peripheral triangular fibrocartilage complex tears.

Morphologic Characteristics of the Sigmoid Notch of the Distal Radius for Patients With Peripheral Triangular Fibrocartilage Complex Tear.

The distal radioulnar joint (DRUJ) is stabilized by the bony anatomy of the contact surfaces. The authors analyzed the morphologic characteristics and radiologic parameters at the sigmoid notch of patients with a peripheral triangular fibrocartilage complex (TFCC) tear compared with asymptomatic patients. Preoperative axial computed tomography scans were reviewed for 76 wrists with peripheral TFCC injuries, including foveal avulsion, and 76 wrists of age- and sex-matched control subjects. The authors used axial computed tomography scans of the DRUJ to classify the patients into 4 groups according to the type of sigmoid notch, namely, flat face, ski-slope, C-type, and S-type. They also measured the tilting angle, depth, width of the sigmoid notch, and radioulnar ratio (RUR). Statistical analyses were performed with the chi-square test or paired t test (P<.05). The mean proportions of flat face, ski-slope, C-type, and S-type sigmoid notches among patients with peripheral TFCC injuries were 42%, 22%, 29%, and 7%, respectively, whereas those for the control group were 33%, 1%, 65%, and 1%, respectively (P<.05). The tilting angle was lower (TFCC injury, 84.5°; control, 86.2°; P<.05) and the RUR was significantly higher (TFCC injury, 0.67; control, 0.56) in the TFCC group, particularly for men (P<.05). Depth (TFCC injury, 1.0 mm; control, 1.3 mm; P>.05) and width (TFCC injury, 14.8 mm; control, 14.5 mm; P>.05) were similar between the groups. Patients with ski-slope or dorsally tilted sigmoid notches may be at greater risk for peripheral TFCC injuries. [Orthopedics. 2021;44(6):e729-e734.].

The Hook Test Is More Accurate Than the Trampoline Test to Detect Foveal Tears of the Triangular Fibrocartilage Complex of the Wrist

To evaluate the accuracy of the trampoline and hook tests, used in the arthroscopic assessment of triangular fibrocartilage complex (TFCC) tears compared with arthroscopic direct visualization of the radiocarpal joint (RCJ) and of the distal radial ulnar joint (DRUJ). In total, 135 patients (97 male, 38 female, mean age 43.5 years) were divided into 2 groups: (1) 80 patients with chronic ulnar-sided wrist pain and positive fovea sign and (2) 55 patients with other complaints. TFCC was assessed by RCJ and DRUJ arthroscopy and by the trampoline and hook tests to detect rupture of distal and proximal components of the TFCC. Accuracy, specificity, sensitivity, and likelihood ratio of the 2 diagnostic methods were measured and compared, using RCJ and DRUJ arthroscopy as reference. The trampoline and the hook tests showed an overall accuracy of 70.37% and 86.67%, respectively. The accuracy of the trampoline test was similar for distal (69%), proximal (66%), and complete (73%) TFCC tears. The hook test was more accurate when evaluating proximal (97%) and complete (98%) tears, rather than distal lesions (75%). Sensitivity for the trampoline and hook tests was 75.00% and 0.00% (P < .001) for distal tears and 78.85% and 100.00% (P < .001) and 58.33% and 100.00% (P < .001) for complete or isolated proximal tears, respectively. Specificity for the trampoline and hook tests was 67.27% and 96.36% (P < .001) respectively. The trampoline and hook tests can assure accurate diagnosis of peripheral TFCC tear. The hook test shows greater specificity and sensitivity to recognize foveal TFCC tears. Values of positive likelihood ratio suggest a greater probability to detect foveal laceration of peripheral TFCC for the hook test than for the trampoline test. These findings suggest that DRUJ arthroscopy is not necessary to confirm foveal incompetence of the TFCC, if the hook test is positive. Level II, retrospective diagnostic trial.

Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy.

To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist. In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions. For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears. The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.

Should all superficial peripheral triangular fibrocartilage complex tears be arthroscopically repaired?

Background Superficial peripheral triangular fibrocartilage complex (TFCC) tears are commonly encountered during diagnostic wrist arthroscopy done for other causes of wrist pain. The authors hypothesized that debridement of these tears in symptomatic post-traumatic superficial tears may be a sufficient alternative to arthroscopic repair. Patients and methods The authors conducted a prospective study including 29 patients with superficial peripheral TFCC tears (with no distal radioulnar joint instability) treated arthroscopically between 2011 and 2014. There were 26 males (89.7%) and three females (10.3%), with a mean age of 32.90 years (range: 21–59 years). The dominant hand was affected in 19 patients (65.5%) and the nondominant in 10 patients (34.5%). Patients were divided into two groups. The first group included 14 patients to whom arthroscopic shaving and debridement (debridement group) were done. The second group included 15 patients for whom arthroscopic repair (repair group) was done using the outside-in technique. Patients were evaluated with the visual analog scale (VAS) for pain, the quick score disability arm shoulder hand (DASH) score, and Mayo modified wrist score. Results There were no statistically significant differences in pain, disability, and functional scoring between both groups in the short-term follow-up. In the first group, the mean follow-up period was 21.87 months. The mean VAS improved from 3.53 to 1.07, the mean quick DASH score improved from 36.33 to 21.60, and the mean Mayo modified wrist score improved from 71.33 to 85.33. In the second group, the mean follow-up period was 19.71 months. The mean VAS improved from 3.86 to 1, the mean quick DASH score improved from 34.43 to 19.79, and the mean Mayo modified wrist score improved from 77.14 to 90. Conclusion Arthroscopic debridement gives comparable short-term results to repair in symptomatic superficial tear of the TFCC presenting with pain and no instability. Debridement group showed less complication and reoperation rate.

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.

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

To compare the outcomes of arthroscopic repair of peripheral ulnar-side triangular fibrocartilage complex (TFCC) tears between patients with and without ulnar-plus variance (UPV) and to identify factors associated with index surgery failure in these patients. We retrospectively analyzed 50 consecutive patients who underwent arthroscopic repair of peripheral ulnar-side TFCC tears from June 2014 to February 2018. We selected patients who were aged at least 18 years and underwent arthroscopic repair of peripheral ulnar-side TFCC tears. We excluded those with a fractured or dislocated wrist, ulnar impaction syndrome, degenerative or inflammatory arthritis of the wrist, or neurologic conditions that affect upper-extremity function, as well as those who received less than 12 months' follow-up. We evaluated the patients with a visual analog scale for pain in 3 domains (overall, with hard work, and at rest), the Patient-rated Wrist Evaluation, range of motion, and grip strength. Clinical outcomes and arthroscopic findings were compared between patients with and without UPV (UPV group and non-UPV group, respectively). We calculated the relative risk and 95% confidence interval for younger age (<30 years), sex, UPV, and coexisting degenerative central TFCC tear (type 2 tear) to determine the risk factors for arthroscopic repair failure. No significant differences were noted between the 2 groups regarding visual analog scale pain and Patient-rated Wrist Evaluation scores and rates of excellent or improved outcomes (P > .05). Arthroscopic repair failure was found in 4 patients. A coexisting type 2 TFCC tear was the only significant risk factor (relative risk, 49.5; 95% confidence interval, 2.94-83.96; P= .007) for arthroscopic repair failure. UPV did not significantly affect the outcomes of arthroscopic repair of peripheral ulnar-side TFCC tears. However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients. Level IV, prognostic study.

Designing a 20 mm incision to protect the dorsal branch of the ulnar nerve during arthroscopic repair of triangular fibrocartilage complex injuries: Cadaver study and preliminary clinical results

The ulnar-sided approach for arthroscopic peripheral triangular fibrocartilage complex (TFCC) repair may be associated with injury to the dorsal branch of the ulnar nerve (DBUN). The goal of this study was to develop a small incision to help minimize DBUN injury. Ten cadaveric upper limbs were used to measure the anatomic parameters of the DBUN. Based on these measured anatomical relationships, a 20 mm longitudinal incision with the ulnar styloid process as the midpoint was designed to explore and protect the DBUN. Three additional cadaveric upper limbs were used to test the feasibility of this method. Then this method was applied in 15 patients with TFCC injury (IB type). In 10 cadavers, the DBUN was located volar to the ulnar styloid process. The mean linear distance between the DBUN and the ulnar styloid process was 8.04 mm (range: 7.02–8.82mm) in the transverse-volar direction and 13.78 mm (range: 11.06–16.02mm) in the longitudinal-distal volar direction. In three additional cadavers, the DBUN was successfully explored and retracted with this incision, creating a safer space for passing sutures and tying knots. This modified method was used successfully in 15 patients, and the DBUN was protected during surgery. There were no complications, and most importantly, no injuries to the DBUN at the 6-month follow-up visit. Therefore, we recommend that a 20 mm longitudinal incision with the ulnar styloid process as the midpoint be made prior to passing sutures during the arthroscopic repair of TFCC tears to avoid injuring the various branches of the DBUN.

Long-Term Outcomes of All-Arthroscopic Pre-Tied Suture Device Triangular Fibrocartilage Complex Repair.

Background A pre-tied suture device has been utilized for all-arthroscopic peripheral triangular fibrocartilage complex (TFCC) repairs with promising early clinical results. Purpose The purpose of this study was to evaluate long-term functional outcomes of these repairs. Patients and Methods A retrospective review of patients undergoing arthroscopic TFCC repair was performed. Inclusion criteria were the Palmer type 1B TFCC tears diagnosed on arthroscopy and repaired using the all-arthroscopic pre-tied suture device. Patients with any evidence of concomitant wrist injury at the time of surgery, history of prior wrist surgery, or nonrepairable and nonperipheral TFCC tears were excluded. Postoperative complications, range of motion, grip strength, and outcome assessments were recorded for each patient. Results Eleven patients (mean age, 36 years; range, 20-64 years) satisfied our inclusion criteria and comprised the study cohort. The mean follow-up period was 7.0 years (range, 4.3-10.9 years). Mean range of motion of the wrist revealed flexion of 76 ± 11 degrees and extension of 73 ± 12 degrees. Mean grip strength was 98 ± 15% of the nonsurgical extremity. QuickDASH, modified Mayo, and patient-rated wrist evaluation (PRWE) average scores were 9 ± 8, 80 ± 6, and 12 ± 12, respectively. No surgical complications were observed and no patient required any further surgical intervention. Conclusions Our cohort of patients following all-arthroscopic pre-tied suture device repair of isolated Palmer type 1B TFCC tears demonstrated excellent clinical function at a mean follow-up of 7 years. These findings indicate that the pre-tied suture device is a reliable, safe, effective, and most importantly, durable treatment option for repair of peripheral TFCC tears. Level of Evidence This is a Level IV, therapeutic study.

Value of conventional wrist physical examination in detection of injury to triangular fibrocartilage complex

Objective To evaluate conventional wrist physical examination in detecting injury to the triangular fibrocartilage complex (TFCC). Methods A retrospective study was conducted of the 118 patients (119 wrists) who had been admitted from January 2013 to October 2017 to Hand Surgery Department, Beijing Jishuitan Hospital for wrist arthroscopic surgery. All of them underwent wrist physical examination preoperatively for conventional index tests for TFCC injury like ulnar fovea sign, piano-key test, distal ulnar ballottement test and ulnocarpal stress test. They were 68 males and 50 females with a mean age of 32 years. The results of physical examination were compared with the arthroscopic findings to calculate the sensitivity, specificity, positive/negative predictive value (PPV/NPV) and+/- likelihood ratio (LR) of each index test. In addition, we combined the results of any 2 tests to increase the capability of detecting peripheral TFCC injury. Results The diagnostic values of each index test were achieved by comparison between the results of physical examination and the arthroscopic findings: (1) ulnar fovea sign: sensitivity=0.648, specificity=0.742; (2) piano key test: sensitivity=0.817, specificity=0.735; (3) distal ulnar ballottement test: sensitivity =0.927, specificity=0.647; (4) ulnocarpal stress test: sensitivity=0.825, specificity=0.500. The combination of any 2 tests produced 3 new index tests, of which the most valuable combination was ulnar fovea sign & distal ulna ballottement test, with a sensitivity of 0.598, a specificity of 0.941, a PPV of 0.961 and a +LR of 10.14, Conclusions The signs elicited in physical examination and special tests can be helpful in the diagnosis of TFCC injuries. However, as the value of any single test is not enough, we should clinically combine the results of ulna fovea sign and distal ulna ballottement test to increase the capability of detecting peripheral TFCC injury. Key words: Triangular fibrocartilage; Physical examination; Arthroscopy; Sensitivity; Specificity

Arthroscopic Transosseous Repair for both Proximal and Distal Components of Peripheral Triangular Fibrocartilage Complex Tear.

Background:Tears of the triangular fibrocartilage complex (TFCC) can result in instability of the distal radioulnar joint (DRUJ) and ulnar-sided wrist pain. This study evaluates clinical results of arthroscopic transosseous repair for both proximal and distal components of TFCC tear with DRUJ instability.Materials and Methods:Ten patients who underwent both proximal component and distal component of TFCC repair were retrospectively reviewed. The proximal component of TFCC was repaired through arthroscopic one-tunnel transosseous suture technique, and the combined distal component tear was repaired to the ulnar capsule using same transosseous tunnel in all cases. Visual analog scale (VAS) score for pain, wrist range of motion, grip strength, and postoperative complications were evaluated after a mean followup period of 23.5 months, and each patient was rated according to modified Mayo wrist score and quick disabilities of the arm, shoulder, and hand (DASH) questionnaire.Results:On arthroscopic findings, the hook test confirmed the proximal component of the TFCC tear and visible capsular detachment from TFCC confirmed combined distal component tear in all patients. At final followup, 7 patients had normal stability of DRUJ and 3 patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 4.1 to 0.7, and grip strength was increased significantly. The modified Mayo wrist score and Quick DASH score showed significant functional improvement. No surgery-related complications occurred.Conclusions:Arthroscopic one-tunnel transosseous TFCC foveal repair and simulatneous transosseous capsular repair of distal component can be a safe and effective strategy for repair of complete TFCC tear combined with DRUJ instability.

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.

Triangular Fibrocartilage Complex Repair and Ulna Variance: A Systematic Review.

This purpose of the study was to conduct a systematic review of available literature regarding the association between ulnar variance and outcomes after repair of peripheral traumatic tears of the triangular fibrocartilage complex (TFCC). A systematic literature search of the medical literature about peripheral tears of the TFCC was performed. We selected seven studies comparing clinical outcome and ulnar variance in patients with peripheral TFCC tears. We evaluated quality of the articles using both the Structured Effectiveness Quality Evaluation Scale (SEQES) and Sackett's Level of Evidence (LOE). The outcomes were objective or self-assessment scoring systems for the function of the hand, wrist, or upper extremity. Seven articles were evaluated. The SEQES scores varied from 19 to 28, with a mean of 23. Five studies reported no association between ulnar variance and clinical outcome, and 2 studies reported an association. The studies reporting no association either excluded or did not mention the cases of unstable distal radioulnar joint (DRUJ). This systematic review did not demonstrate strong evidence regarding the association between ulnar variance and outcomes after TFCC repair. As most of the studies did not distinguish between capsular and foveal tears which can affect DRUJ stability, further studies looking at this point are necessary to determine whether ulnar shortening osteotomy has an added value for better outcomes after TFCC repair.