Triangular Fibrocartilage Complex Research Articles

Role of Vickers Ligament in the Pathogenesis of Madelung Deformity.

The Vickers ligament is thought to hinder the growth of palmar ulnar radius by tethering the lunate to the radius, leading to Madelung deformity. The purpose of this study was to clarify the nature of the Vickers ligament and investigate its pathogenesis in Madelung deformities based on our observation of the Vickers ligament. All 22 patients (33 wrists) with Madelung deformities treated surgically between 2018 and 2022 were included. The diagnosis was confirmed radiographically in all patients. The three-dimensional computed tomography (3D-CT) data of 16 patients (19 wrists) were available. Magnetic resonance imaging (MRI) data were available for 9 patients (14 wrists). Wrist arthroscopy was used in 4 patients. The Vickers ligament was resected and submitted for histopathological examination in 8 patients. Radiographic outcomes, 3D-CT, MRI, arthroscopy, surgical findings, and histopathology of the Vickers ligament were evaluated. The 3D-CT revealed that the Vickers ligament originated in the metaphysis and formed a metaphyseal defect at the palmar ulnar radius. In the sequential MR coronal images, the Vickers ligament could be divided into 3 branches, extending to the lunate, triquetrum and ulnar styloid. Arthroscopy and surgical findings revealed that the nature of the Vickers ligament was the stretched palmar ligament of the wrist. The histopathology results revealed ligamentous tissue and fibrocartilaginous metaplasia with a structure similar to that of the triangular fibrocartilage complex (TFCC). The Vickers ligament is not a separate aberrant ligament. The nature of the Vickers ligament is a combination of the stretched TFCC ligament (palmar radioulnar ligament, ulnotriquetral ligament and ulnolunate ligament) and radiolunate ligament. The possible pathogenesis of Madelung deformity might be focal early epiphyseal closure at the middle part of the sigmoid notch, which leads to focal growth retardation of the radius and pulls palmar ligaments proximally to form the Vickers ligament.

Effect of dorsal capsular imbrication on intraoperative DRUJ instability following arthroscopic TFCC repair surgery

BackgroundTo assess the clinical outcomes and identify the ideal indication for implementing dorsal distal radioulnar joint (DRUJ) capsular imbrication after triangular fibrocartilage complex (TFCC) repair in cases of DRUJ instability.MethodsWe conducted a retrospective study on patients who underwent arthroscopic TFCC repair between 2016 and 2021. Inclusion criteria comprised a symptomatic ulna fovea sign for over 6 months and dorsal DRUJ subluxation on magnetic resonance imaging. A total of 225 patients were divided into two groups: Group 1 (135 cases) with a negative ballottement test after “Cross-form TFCC repair” (CR) and Group 2 (90 cases) with a positive ballottement test after “Cross-form TFCC repair” and augmented DRUJ stability through dorsal DRUJ capsular imbrication (CR + DCI). Pain visual analog scale score (VAS), grip strength, modified Mayo Wrist Score (MMWS), wrist range of motion (ROM), and patient-reported outcomes (PROMs) were assessed for a minimum of 3 years postoperatively.ResultsBoth groups showed significant improvements in pain VAS score, grip strength, wrist ROM, MMWS, and PROMs between the preoperative and postoperative periods (all P < 0.05). Recurrent DRUJ instability occurred in 3.7% and 1.1% of patients in the “CR” and “CR + DCI” groups, respectively, with a significant difference. Despite the “CR + DCI” group initially exhibiting inferior ROM compared with the “CR” group, subsequently, no significant difference was noted between them.ConclusionsDorsal DRUJ capsular imbrication effectively reduces postoperative DRUJ instability rates, enhances grip strength, and maintains wrist ROM in patients with a positive intra-operative ballottement test after arthroscopic TFCC repair.

Post-surgical Rehabilitation Guidelines for Triangular Fibrocartilage Complex Foveal Repair: A Survey of Australian Hand and Wrist Surgeons.

Background: To restore distal radioulnar joint stability following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be necessary. Post-surgery rehabilitation is prescribed to restore wrist and hand function; however, no universally accepted or definitive rehabilitation protocol currently exists. The aim of this study was to survey hand and wrist surgeons regarding their recommended postoperative rehabilitation protocols following TFCC foveal repair surgery. Methods: Australian hand and wrist surgeons were invited to complete a descriptive survey containing 10 questions. Questions included clinical recommendations for wrist and forearm immobilisation, range of motion (ROM) exercise timeframes and surgeon experience of TFCC rupture. Descriptive statistics and between-group (TFCC rupture vs. no-rupture) comparisons (Pearson's Chi2) were calculated. Results: Thirty-one surgeons completed the survey. Recommendations for post-surgery immobilisation ranged from 'not required' to 8 weeks (mode 6 weeks). Wrist and forearm ROM commencement time ranged from 'immediately' to 'later than 8 weeks' (mode 6 weeks). The most recommended orthosis was a 'sugar-tong' (57%). Thirty-seven percent (37%) reported experience of post-surgery re-rupture. Conclusions: While surgeon recommendations varied, the majority recommended 4- to 6-week timeframe for immobilisation and ROM exercise commencement. Additional clinical research is recommended to evaluate whether postoperative rehabilitation decisions influence patient outcomes. Level of Evidence: Level V (Therapeutic).

Evaluation and Management of Triangular Fibrocartilage Complex (TFCC) Injuries in the Athlete

Evaluation and Management of Triangular Fibrocartilage Complex (TFCC) Injuries in the Athlete

Wrist &amp; Hand

The June 2024 Wrist &amp; Hand Roundup360 looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review.

A modified partial wedge-shaped metaphyseal ulnar osteotomy for the treatment of ulnar impaction syndrome with reverse oblique sigmoid notch.

We describe a modified metaphyseal ulnar osteotomy to treat ulnar impaction syndrome with a reverse oblique sigmoid notch. Based on a computational analysis of radiographs, a modified wedge metaphyseal ulnar osteotomy was devised with its apex positioned at the ulnar styloid base to avoid impaction between the sigmoid notch and ulnar head. Subsequently, nine patients with ulnar impaction syndrome and a reverse oblique sigmoid notch underwent this operation, combined with arthroscopic exploration and transosseous triangular fibrocartilage complex repair. The mean follow-up was 14 months. All patients achieved bone union within 5 weeks, with no degenerative changes being observed during the follow-up assessments. The final follow-up assessments revealed decreases in ulnar variance and in the scores for Visual Analogue Scale, Quick Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Wrist Evaluation. All patients achieved excellent or good grades on the Modified Mayo Wrist Score. This technique is effective in treating the ulnar impaction syndrome with a reverse oblique sigmoid notch.Level of evidence: IV.

Clinical Outcomes and Failure Rate of Triangular Fibrocartilage Complex Foveal Repair Were Comparable between Arthroscopic and Open Techniques.

Background: This study compared clinical outcomes between arthroscopic and open repair of triangular fibrocartilage complex (TFCC) foveal tears in chronic distal radioulnar joint (DRUJ) instability patients. Methods: A total of 79 patients who had gone through foveal repair of TFCC using arthroscopic technique (n = 35) or open technique (n = 44) between 2016 and 2020 were retrospectively analyzed. The visual analog scale (VAS) score for pain, active range of motion (ROM), grip strength, Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and Patient-Rated Wrist Evaluation (PRWE) score at 2-4-6-12-24 months postoperatively were compared between two groups. Results: Two years after the operation, clinical parameters (VAS, MMWS, DASH, and PRWE), grip strength, and ROM showed significant advancement in the two groups in comparison to their values measured preoperatively (p < 0.001). Nonetheless, we could not identify any statistically significant differences in the above clinical factors between the two groups. The arthroscopic group showed a better flexion-extension arc at 2 months and supination-pronation arc at 2 and 4 months than the open group (p < 0.001). There were no significant differences between the two groups at 2 years postoperatively. Ten patients (12.6%) had recurrent instability (three in the arthroscopic group and seven in the open group, p = 0.499). Similarly, both groups showed no significant difference in the return to work period. Conclusions: Arthroscopic foveal repair of TFCC provided similarly favorable outcomes and early recovery of pain and ROM compared to open repair.

No evidence for the superiority of 3 T MRI over 1.5 T MRI for diagnosing wrist ligamentous lesions: a systematic review and meta-analysis

PurposesOur aim was to determine the diagnostic accuracy of native MRI regarding different ligamentous lesions of the wrist and to analyze the influence of technical characteristics, such as field strength, application of fat saturation, 3D sequences, and wrist coils. MethodsThe systematic search was performed using MEDLINE, Embase, and CENTRAL databases. Studies that were published before the 12th of February 2024 were included. All studies comparing the diagnostic accuracy of native wrist MRI to that of wrist arthroscopy for suspected ligamentous lesions were included. Results were analyzed by anatomic localization and technical aspects of the MRI. To assess the quality of included studies, we used the revised QUADAS-2 tool. ResultsThe systematic search revealed 5,181 articles. Thirty-seven studies, reporting 3893 ligamentous lesions, were eligible for inclusion. The studies displayed heterogeneity in terms of technical conditions, such as field strength, the use of wrist coils, the application of 3D sequences and fat saturation. Research methods also varied. Overall sensitivity and specificity were 0.78 (0.66 – 0.86) and 0.81 (0.70 – 0.89) for 1.5T MRI, while sensitivity was 0.73 (0.68 – 0.78) and specificity was 0.90 (0.59 – 0.98) for 3T MRI. There was no significant difference between the two subgroups (p=0,3807 and p=0,4248). Sensitivity was 0.82 (0.75 – 0.87) for triangular fibrocartilage complex (TFCC) lesions, 0.63 (0.50 - 0.74) for scapholunate ligament (SL) tears, and 0.41 (0.25 – 0.60) for lunotriquetral ligament (LT) lesions. Specificity for TFCC lesions was 0.82 (0.73 – 0.89), for SL tears 0.86 (0.73 - 0.93), and for LT lesions 0.93 (0.81 – 0.98). ConclusionThe sensitivity and specificity of MRI is influenced by the anatomic location of the lesion and technical conditions. In terms of diagnostic accuracy, no significant difference was found between 1.5T and 3T MRI. Level of EvidenceIII. Systematic review of Level II. - III. studies.

Trends in Domestic and International Clinical Research on Korean Medicine Treatments for Triangular Fibrocartilage Complex Injury

Trends in Domestic and International Clinical Research on Korean Medicine Treatments for Triangular Fibrocartilage Complex Injury

The Natural History of Non-operatively Treated Traumatic Triangular Fibrocartilage Complex Tears: A Systematic Review

Abstract Purpose Operative treatment of triangular fibrocartilage complex (TFCC) tears has been well researched; however, data regarding nonoperative management is mixed and scarce. Our review aimed to utilize available data to formulate conclusions regarding treatment algorithms for this heterogeneous injury group. Methods A thorough literature review was performed in Medline (OVID), Embase, Cochrane Library, and PubMed databases with search terms including “triangular fibrocartilage complex” and variations on the full term including “triangular fibrocartilage” or “TFCC,” alongside “non-operative” and “conservative.” Results were then subject to inclusion criteria, ultimately identifying eight studies. Results The studies involved a total of 425 patients and 427 wrists for analysis. The mean age ranged from 30.7 years to 60.4 years. 53.6% of patients were male. The mean follow-up ranged from 12 months to 7 years, with an overall mean follow-up period of 27 months. Primary endpoints focused on various functional outcome scores, range of motion, grip strength, and pain. The nonoperative management of TFCC tears resulted in noninferior and comparable outcomes to operative management. Conclusion Our review identified that the nonoperative management of Palmer-type IB tears with a short period of above-elbow immobilization was an effective treatment option with good functional outcome scores. The nonoperative management of general TFCC tears resulted in comparable functional outcomes when viewed alongside results from other systematic reviews. Risk factors for developing a poor functional outcome or requiring operative management included distal radioulnar joint subluxation, short-arm immobilization, and full tears of the foveal attachment. However, further randomized controlled trials with homogenous data collection are required to make further conclusions regarding the management of this condition.

Radiocarpal Osteochondral Allografts for Wrist Pain Postproximal Row Carpectomy

Abstract Background Surgical options for patients with recurrent wrist pain after salvage procedures, such as proximal row carpectomy (PRC), are limited and primarily result in total wrist arthrodesis (TWA). Osteochondral allografting (OCA) offers an additional option to address refractory wrist pain due to arthritis while preserving some range of motion. Case Description A 65-year-old, right hand dominant male developed chronic wrist pain, secondary to untreated scapholunate and triangular fibrocartilage complex ligament tears. The patient underwent a PRC, radial styloidectomy, and partial wrist denervation with good initial pain relief. Two years later, symptoms returned with radiographs demonstrating capitate sclerosis. A salvage arthroplasty with OCA produced relief of symptoms. Literature Review Refractory wrist pain after salvage procedures have traditionally been managed with TWA or less commonly, wrist arthroplasty. Capitate resurfacing and interposition have expanded indications for PRC. OCA is a chondral replacement procedure that utilizes cadaveric cartilage allograft plugs to replace damaged cartilage in various articular joint surfaces. Although OCA used in the lower extremity and shoulder has demonstrated improved pain relief and return of function, it has not been reported in the wrist. Clinical Relevance There are limited options for refractory wrist pain after salvage procedures. We present an additional alternative to TWA, by resurfacing the radiocarpal joint affected by chondromalacia after a PRC. This option offers another treatment modality for recurrent wrist pain while still preserving some element of range of motion.

Research hotspots and trend of wrist arthroscopy: A bibliometrics analysis from 2013 to 2023.

Wrist arthroscopy technology is a surgical technology invented in recent years and widely used in clinical treatment of various wrist diseases. This study uses the methods of bibliometrics and visual analysis to understand the global research status, research hotspots, and future development trends of wrist arthroscopy. The relevant literature of global publications on wrist arthroscopy from 2013 to 2023 was extracted from the Web of Science Core Collection database, and the annual output, cooperation, hot spots, research status, and development trend of this field were analyzed by using the bibliometric software (VOSviewers, CiteSpace, and the R package "Bibliometrix"). A total of 635 articles were included, from 2013 to 2023, the number of publications related to wrist arthroscopy showed an overall upward trend, the USA, France, and China are the top 3 countries in terms of the number of publications, whereas Mayo Clinic is the institution with the highest number of publications, Ho PC holds a core position in this field, keyword analysis indicates that the research hotspots are the applications of wrist arthroscopy in triangular fibrocartilage complex injuries, scaphoid nonunion, and avascular necrosis of the lunate. Wrist arthroscopy has shown tremendous potential in treating various wrist diseases. However, there are still some challenges in its research domain. With continuous deep research, strengthened international collaboration, and ongoing technological advancements, wrist arthroscopy has the potential to become the standard treatment in hand surgery, offering more efficient and safer treatment options for patients worldwide.

The Contribution of the Distal Oblique Band to Distal Radioulnar Joint Stability

The distal radioulnar joint (DRUJ) is supported by an array of dynamic and static stabilizers, of which the triangular fibrocartilage complex (TFCC) is the most important, and the distal interosseous ligament is next in importance. The distal oblique band (DOB) is an identifiable component of the distal interosseous ligament, found in a subset of the population. Our objective was to determine the contribution of the DOB to DRUJ stability in the presence of a disrupted TFCC. Twenty-three above-elbow specimens were prepared by removing the TFCC and the DRUJ joint capsule, preserving the distal interosseous ligament and the pronator quadratus. Cadavers were stratified into two groups-those with, and those without a DOB. A bone plate and screws were attached to the ulna; then, a transverse load was applied to failure, creating a diastasis between the radius and ulna. The group with a DOB had a mean load at failure of 160.7 ± 46.5 N. The group without a DOB had a mean load at failure of 148.0 ± 26.3 N. Stiffness prior to failure was 16.9 N/mm in the group with a DOB and 12.4 N/mm in the group without a DOB. The current results indicate that the DOB may not substantially contribute to DRUJ stability in the presence of a disrupted TFCC. Stability of the DRUJ after TFCC injury may not be substantially improved by the presence of a DOB. Thus, the clinical importance of DOB reconstruction remains unclear.

Arthroscopic Repair of Combined Triangular Fibrocartilage Complex, Lunotriquetral Ligament, and Ulnocarpal Ligament Tears

The ulnocarpal ligament complex (UCLC), consisting of the ulnotriquetral, ulnolunate, and ulnocapitate ligaments, plays a pivotal role in maintaining ulnocarpal joint stability and is closely linked to the palmar radioulnar ligament (PRUL), preventing dorsal ulnar translation. Often, tears in the PRUL and UCLC coincide with lunotriquetral interosseous ligament (LTIL) tears as the result of their strong anatomical connections. Biomechanical studies have demonstrated that ulnar-shortening osteotomy enhances stability in the distal radioulnar joint, lunotriquetral joint, and UCLC by tightening the ligaments and capsules. Our technique aims to replicate the effects of ulnar-shortening osteotomy by plicating the volar triangular fibrocartilage complex (TFCC) and capsule, addressing combined TFCC, UCLC, and LTIL pathologies with a single-strand suture approach. Although surgical treatments exist for ulnotriquetral and LTIL tears, addressing concurrent PRUL or palmar TFCC tears has remained a challenge. This article presents a simple technique for managing these complex ulnar wrist pathologies.

3D MRI of the Wrist: Anatomy and Clinical Applications With Comparison to 2D MRI

The wrist joint has complex anatomy and is commonly involved in traumatic injuries. Magnetic resonance imaging (MRI) is routinely used to evaluate various wrist structures including the ligaments, triangular fibrocartilage complex (TFCC), tendons, and articular cartilage. While the 2D (2-dimensional) MR imaging offers high spatial resolution, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), it has some limitations due to relatively thick slices, limited fluid contrast, and the need for image acquisition in multiple planes. Isotropic 3D MR imaging can overcome these limitations by acquiring a volumetric dataset with thin contiguous slices enabling multiplanar reconstructions in arbitrary, though structure-specific planes. Recent advances have reduced the acquisition duration of 3D imaging datasets making them more time efficient than 2D MRI thus enabling clinical implementation. In this article, we will review the main concepts on wrist anatomy and imaging, present illustrative cases using recent technical advances of 3D MRI and compare 2D vs. 3D benefits for various wrist structures and their pathologies.

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.

Combined Effect of Shock Wave to Conventional Physical Therapy Program on Wrist Joint Pain Intensity in Treatment of Triangular Fibrocartilage Complex

Combined Effect of Shock Wave to Conventional Physical Therapy Program on Wrist Joint Pain Intensity in Treatment of Triangular Fibrocartilage Complex

Ulnar peripheral tears of the triangular fibrocartilage complex: multiplanar approach of injury patterns with a focus on CT arthrography

Ulnar peripheral tears of the triangular fibrocartilage complex: multiplanar approach of injury patterns with a focus on CT arthrography

Current concepts and new trends in management of isolated triangular fibrocartilage complex injuries.

The triangular fibrocartilaginous complex is made of multiple components, of which the palmar and dorsal radioulnar ligaments play an important role in distal radioulnar joint stability. The ulnar wrist ligaments may be injured during forearm and wrist trauma. There are several aspects of triangular fibrocartilaginous complex management that are still open to debate. The aim of the present study was to review the current concepts and discuss emerging trends to better elucidate and treat this important ligament complex.Level of evidence: V.

Arthroscopic Thermal Shrinkage of Lunotriquetral Ligament Incomplete Tear without Triangular Fibrocartilage Complex Perforation

Abstract Background Few studies have reported the clinical results of arthroscopic debridement and thermal shrinkage for partial lunotriquetral (LT) ligament injury. Purpose We estimated the outcomes of arthroscopic thermal shrinkage of a traumatic LT ligament incomplete tear without triangular fibrocartilage complex (TFCC) perforation. Methods We evaluated the results of 24 patients. The mean follow-up was 16 months. Radiographs were examined for ulnar variance (UV) and radioulnar distance on a true lateral radiograph, and wrist function was assessed based on grip strength, Mayo wrist score, and Disabilities of the Arm, Shoulder, and Hand (DASH) score, both pre- and postoperatively. Results On preoperative magnetic resonance imaging (MRI), no obvious LT ligament tear was observed in any of the patients. The preoperative LT shear test was positive in 19 cases, while the LT ballottement test was positive in 18 cases and the ulnar stress test in 16 cases. Preoperatively, the average radiographic UV was 2.1 mm and the average radioulnar distance was 0.9 mm. The LT tear type was a flap tear in 22 cases and bucket handle tear in 2 cases arthroscopically. The visual analog pain scale score improved postoperatively (from 7.5 to 0.4). The average grip strength improved from 72.7% preoperatively to 89.8% postoperatively. The Mayo wrist score was excellent/good in 6/15 cases and fair in 3 cases, with the scores ranging from 68 to 87. The average DASH score improved from 36.8 to 7. Conclusion We should be careful to differentiate LT ligament tears from TFCC lesions in the cases with ulnar wrist pain, because LT ligament tears may not be detected by MRI. Arthroscopic thermal shrinkage for traumatic LT ligament tear can be an effective treatment. Level of Evidence Level IV.