Triangular Fibrocartilage Complex Foveal Repair Research Articles

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).

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.

Effective Functional Recovery after Triangular Fibrocartilage Complex Foveal Repair

Effective Functional Recovery after Triangular Fibrocartilage Complex Foveal Repair

Foveal triangular fibrocartilage complex pathology: a potentially under-recognized injury.

The primary aim of the present study was to present a case series of 24 patients with foveal triangular fibrocartilage complex (TFCC) injuries that were treated with arthroscopically assisted TFCC foveal repair. In total, 19 patients had a stable distal radioulnar joint (DRUJ) and five had an unstable DRUJ. Despite this, all patients were found to have a foveal tear upon DRUJ arthroscopy. Magnetic resonance imaging (MRI) scans detected only eight out of 23 patients with foveal injuries. In addition to their foveal injury, 19 of the 24 patients had additional pathology that required treatment. At a mean follow-up of 18 months, there was a statistically significant improvement in pain, range of motion, grip strength and functional scores. In this study, we demonstrate that having a stable DRUJ upon clinical examination and normal MRI findings does not rule out foveal TFCC injury and a high index of clinical suspicion is needed when managing patients with ulnar sided wrist pain.Level of evidence: IV.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists

BackgroundFollowing injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no “gold standard” rehabilitation protocol currently exists. PurposeTo describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery. Study DesignCross-sectional descriptive study. MethodsAll Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05. ResultsSurvey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from “not required” to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from “immediately” to “later than 8 weeks,” with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated “Yes.” The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm. ConclusionsRehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

Ulnar positive variance associated with TFCC foveal tear.

The ulnar positive variance (UPV) can be observed on simple radiography due to a triangular fibrocartilage complex (TFCC) foveal tear. This study investigated to identify how much radiographic UPV occurs due to a TFCC foveal tear, which may be misdiagnosed as an ulnar impaction syndrome (UIS). One hundred forty patients who underwent arthroscopic transosseus TFCC foveal repair from March 2013 to March 2019 in our institution were enrolled in this study. Ulnar variances were measured in preoperative, postoperative 6weeks, 1-year follow-up wrist posteroanterior (PA) radiograph, and power grip PA radiograph of the affected wrist and were compared with those of the same patient's unaffected wrist. In the neutral wrist PA radiograph, ulnar variance increased by 0.56mm (p < 0.001) after TFCC foveal tear compared to the unaffected side. In the power grip view, ulnar variance also increased by 0.39mm (p < 0.001) in the affected wrist. The preoperative ulnar positive variance was reduced after an arthroscopic transosseous TFCC foveal repair from 0.56 to 0mm (p < 0.001). No significant statistical difference was observed between an Atzei class 2 and 3 TFCC tear (0.56mm vs. 0.41mm, p = 0.263). This study revealed that TFCC foveal tear induces 0.56mm of radiologic UPV, which was successfully corrected after arthroscopic transosseous TFCC foveal repair. Therefore, UPV associated with TFCC foveal tear should not be misdiagnosed as an UIS. Also, when ulnar shortening osteotomy is planned in case of UIS combined with TFCC foveal tear, the amount of UPV induced by TFCC foveal tear should be considered to prevent over-shortening.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion

To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN). Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation. This study consisted of 66 patients: group I (n= 22) and group II (n= 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P= .94, Quick-DASH: P= .23, grip strength: P=.69, VAS: P= .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P= .59, Quick DASH: P= .82, grip strength: P= .15, VAS: P= .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups. Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair. Level III, retrospective comparative study.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review

Study DesignScoping review. BackgroundRehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time. Purpose of the StudyTo scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery. MethodsA systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery. ResultsNo supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported. ConclusionsTFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

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

The deep components of the triangular fibrocartilage complex (TFCC), which consist of the volar and dorsal radioulnar ligaments (RULs), are crucial for maintaining stability of the distal radioulnar joint. Avulsion of the volar and dorsal RULs from their foveal insertions must thus be diagnosed and treated correctly. We describe our arthroscopic technique for TFCC foveal repair (arthroscopic ligament-specific transosseous repair), in which we repair each of the dorsal and volar RUL to separate points on the fovea. With this "ligament-specific" repair we wish to restore the normal anatomy and physiology of the TFCC.

Revisional triangular fibrocartilage complex (TFCC) repair using arthroscopic one-tunnel transosseous suture: preliminary results.

The purpose of this study was to report the clinical outcome of revision arthroscopic triangular fibrocartilage complex (TFCC) foveal repair using a one-tunnel transosseous suture technique after failed primary TFCC repair. Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique after failed TFCC repair from 2014 to 2018 were retrospectively reviewed. The clinical outcome was evaluated using the Modified Mayo Wrist Score (MMWS) and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. The Visual Analog Scale (VAS) for pain, stability of the distal radioulnar joint (DRUJ), grip strength, and active range of motion (ROM) of the wrist joint also were assessed. This study cohort consisted of eight patients, and their mean time to revision after initial surgery was 15.1months. Previous surgeries were performed using an arthroscopy-assisted mini-open TFCC repair in six cases, an arthroscopic all-inside repair in one case, and an arthroscopic transosseous suture technique in the remaining case. After revisional TFCC foveal repair, all patients demonstrated improved pain and a stable DRUJ. Participants showed improvement in grip strength and mean active wrist ROM. There was improvement in MMWS (from 58.6 to 87.5) and Quick-DASH score (from 46.9 to 12.2) during the mean follow-up of 15.6months (range: 8-36months). Based on the results of this study, remaining ulnar TFCC remnants may be appropriate for sufficient stable repair using an arthroscopic one-tunnel transosseous suture technique after failed primary repair. However, only a small number of patients was examined. A larger number has to be investigated to confirm the promising preliminary results. Level IV, therapeutic case series.

Arthroscopic Repair of Triangular Fibrocartilage Complex Tear

Triangular fibrocartilage complex (TFCC) is an important structure for stability of distal radioulnar joint (DRUJ) and shock absorption of ulnocarpal joint. Recent studies on anatomy and biomechanics of TFCC have revealed that the deep fiber of distal radioulnar ligament plays a key role in stabilizing the DRUJ. Clinicians should evaluate the presence of the instability of DRUJ or ulnar impaction syndrome. If necessary, combined TFCC foveal repair and ulnar shortening osteotomy should be performed. This article introduces the authors’ preferred procedure of arthroscopic TFCC repair with satisfactory clinical outcomes.

The correlation between shape of the sigmoid notch of the distal radius and the risk of triangular fibrocartilage complex foveal tear.

The aim of this study was to analyze the association between the shape of the distal radius sigmoid notch and triangular fibrocartilage complex (TFCC) foveal tear. Between 2013 and 2018, patients were retrospectively recruited in two different groups. The patient group comprised individuals who underwent arthroscopic transosseous TFCC foveal repair for foveal tear of the wrist. The control group comprised individuals presenting with various diseases around wrist not affecting the TFCC. The study recruited 176 patients (58 patients, 118 controls). The sigmoid notch shape was classified into four types (flat-face, C-, S-, and ski-slope types) and three radiological parameters related to the sigmoid notch (namely, the radius curvature, depth, and version angle) were measured. The association of radiological parameters and sigmoid notch types with the TFCC foveal tear was investigated in univariate and multivariate analyses. Receiver operating characteristic curves were used to estimate a cut-off for any statistically significant variables. Univariate analysis showed that the flat-face type was more prevalent in the patients than in the control group (43% vs 21%; p = 0.002), while the C-type was lower in the patients than in the control group (3% vs 17%; p = 0.011). The depth and version angle of sigmoid notch showed a negative association with the TFCC foveal tear in the multivariate analysis (depth: odds ratio (OR) 0.380; p = 0.037; version angle: OR 0.896; p = 0.033). Estimated cut-off values were 1.34 mm for the depth (area under the curve (AUC) = 0.725) and 10.45° for the version angle (AUC = 0.726). The proportion of flat-face sigmoid notch type was greater in the patient group than in the control group. The depth and version angle of sigmoid notch were negatively associated with TFCC foveal injury. Cite this article: Bone Joint J 2020;102-B(6):749-754.

Functional Outcomes Are Similar After Early and Late Arthroscopic One-Tunnel Transosseous Repair of Triangular Fibrocartilage Complex Foveal Tears

To compare outcomes at different time periods following arthroscopic triangular fibrocartilage complex (TFCC) transosseous foveal repair within 6 months, between 6 and 12 months, and more than 12 months from injury. Consecutive patients treated with arthroscopic TFCC foveal repair using the uniform one-tunnel transosseous suture technique by a surgeon from 2014 to 2017 were retrospectively reviewed. The patients were assigned to 1 of 3 groups according to time between injury and surgery. Pain visual analog scale (VAS); grip strength; modified Mayo wrist score (MMWS); Quick disabilities of the arm, shoulder, and hand (QuickDASH) score; and distal radioulnar joint stability were assessed at minimum 2 years postoperatively, along with minimal clinically important difference, and overall patient satisfaction. This study cohort consisted of 80 patients: group A (<6 months, n= 38), group B (6-12 months, n= 20), and group C (>12 months, n= 22). No differences were found among groups in VAS, grip strength, and MMWS and QuickDASH. Overall, patients exhibited significant functional improvement at 2 years (VAS: 3-0, P < .001; grip strength: 77.1%-95.6%, P < .001; MMWS: 65-90, P < .001, QuickDASH: 20.5-4.5, P < .001). Median changes in outcome variables and the proportion of patients achieving minimal clinically important difference for the QuickDASH were similar among groups. Seventy-eight patients (97%) achieved distal radioulnar joint stability, and 70 patients (87%) were satisfied with treatment. Although this current study has insufficient statistical power, the available data suggest that patients with a TFCC foveal tear who underwent arthroscopic transosseous repair surgery more than 12 months after injury could expect to experience similar functional improvement compared with patients who underwent surgery within 6 months or between 6 and 12 months following injury. Level III, retrospective comparative study.

Clinical Outcomes and Factors Influencing These Outcome Measures Resulting in Success After Arthroscopic Transosseous Triangular Fibrocartilage Complex Foveal Repair.

To analyze postoperative outcomes after arthroscopic transosseous triangular fibrocartilage complex (TFCC) foveal repair and identify factors affecting the clinical outcomes. This study retrospectively enrolled patients who were treated for TFCC foveal tears by arthroscopic transosseous TFCC foveal repair. The diagnosis of TFCC foveal tear was made based on medical history, physical examination, and magnetic resonance imaging, with confirmation via arthroscopic examination. Outcome evaluation was completed at a minimum of 2years postoperatively, and patients were classified into 2 groups according to the minimal clinically important difference of the Patient-Rated Wrist Evaluation. Various factors including age, sex, trauma history, body mass index, symptom duration, hand dominance, ulnar variance, subluxation of the distal radioulnar joint, preoperative pain score, and functional status, as well as the cross-sectional area (CSA) of the pronator quadratus (PQ) muscle, were retrospectively analyzed using both univariate and multivariate analyses. During the study period, 42 patients were treated for TFCC foveal tears. The functional status significantly improved after surgery. Overall, 27 and 15 patients showed good and poor functional outcomes, respectively, which were assessed according to the minimal clinically important difference of the Patient-Rated Wrist Evaluation. On univariate analysis, clinical outcomes were better in male patients (P= .035), younger patients (P= .022), and those with higher CSAs of the PQ muscles (P < .001). However, on multivariable logistic regression analysis, only a higher CSA of the PQ muscle was identified as an independent prognostic factor affecting clinical outcome after TFCC foveal repair (P= .004). Arthroscopic transosseous TFCC complex foveal repair led to satisfactory results. However, lower PQ muscle CSA on magnetic resonance imaging was the most independent prognostic factor negatively affecting clinical outcomes. Level III, retrospective comparative study.

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.

Changes in Ulnar Variance after a Triangular Fibrocartilage Complex Tear.

Purpose The relationship between triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood. We hypothesized that a TFCC tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome. Patients and Methods A total of 72 patients who underwent TFCC foveal repair between January 2011 and June 2016 were included in this retrospective study. Among them, 44 patients diagnosed with TFCC foveal tear with distal radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B). We measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography. We also compared them with the ulnar variance of the contralateral (uninjured) wrist. Postoperative clinical outcomes, such as range of motions of the wrist, the visual analog scale (VAS) for pain, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, were assessed. Results Ulnar variance increased after TFCC tears compared with that on the uninjured side in both groups (group A: 0.98 vs. 0.52 mm, p = 0.013; group B: 2.71 vs. 2.13 mm, p = 0.001). Once the TFCC was repaired, ulnar variance decreased (group A: 0.98 to 0.01 mm, p < 0.01; group B: 2.71 to 0.64 mm, p < 0.01). However, it was increased on the last follow-up radiograph (group A: 0.01 to 0.81 mm, p < 0.01; group B: 0.64 to 1.05 mm, p = 0.004). There were no significant improvement of range of motion, except for pronation-supination motion ( p = 0.04). Mean grip strength increased from 56.8 to 70.8% of the contralateral unaffected hand at the last assessment ( p = 0.01). Mean VAS for pain decreased from 7.4 ± 2.5 preoperatively to 2.7 ± 2 postoperatively ( p = 0.001). The QuickDASH score significantly improved from 45 to 9 ( p = 0.001). Conclusion Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain. Level of Evidence This is a therapeutic Level IV study.

Arthroscopic Diagnosis of the Triangular Fibrocartilage Complex Foveal Tear: ACadaver Assessment.

To determine whether the arthroscopic hook and trampoline tests are accurate and reliable diagnostic tests for foveal triangular fibrocartilage complex (TFCC) detachment. Wrist arthroscopy was performed on 10 cadaveric upper extremities. Arthroscopic hook and trampoline tests were performed and videos recorded (baseline). The deep foveal TFCC insertion was then sharply detached. Arthroscopic hook and trampoline tests were repeated. Subsequently, the foveal detachment was repaired via an ulnar tunnel technique and the hook test was repeated for a third time. Videos were independently reviewed at 2 time points by 2 fellowship-trained hand surgeons and 1 hand surgery fellow in a randomized and blinded fashion. Hook and trampoline tests were graded as positive or negative. Proportions of categorical variables were compared via 2-tailed Fisher exact test. Inter- and intraobserver reliabilities were assessed via Cohen kappa coefficient. The sensitivity and specificity of the hook test for foveal detachment diagnosis were 90% and 90%, respectively. There was 90% agreement among all 3 observers for the baseline and foveal detachment hook tests. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the hook test were 0.87 and 0.81, respectively. Seventeen percent of trampoline tests were positive at baseline versus 43% after foveal detachment. The trampoline test had 45% agreement between the 3observers. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the trampoline test were 0.16 and 0.63, respectively. Following ulnar tunnel repair, 20% of hook tests were positive. The hook test is highly sensitive, specific, and reliable for the diagnosis of isolated TFCC foveal detachment. The trampoline test has insufficient reliability to assess foveal detachment. A TFCC foveal repair using an ulnar tunnel technique returns the hook test to baseline. The hook test is a sensitive, specific, and reliable test for the diagnosis of isolated TFCC foveal detachment.

Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear.

Arthroscopic repair of a peripheral triangular fibrocartilage complex (TFCC) tear is a promising, minimally invasive surgical technique, especially in patients with symptomatic distal radioulnar joint (DRUJ) instability. The purpose of this study was to evaluate the clinical result of arthroscopic one-tunnel transosseous foveal repair for peripheral TFCC tears. Sixteen patients who underwent TFCC foveal repair were retrospectively evaluated. The mean follow-up period was 31.1months. The torn TFCC of all patients was repaired with the arthroscopic one-tunnel transosseous foveal repair technique. Postoperative outcomes were evaluated using the visual analogue scale (VAS) for pain, wrist range of motion, grip strength, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and postoperative complications. On arthroscopic examination, all 16 patients showed Palmer 1B type peripheral TFCC tears with foveal disruption. Among them, 13 patients had a proximal component TFCC tear (Atzei class 3) and 3 patients had a complete TFCC tear (Atzei class 2). At the final follow-up, the mean range of the pronation-supination arc (P = 0.03) and grip strength (P = 0.001) was significantly increased. Twelve patients had normal stability of the DRUJ and six patients showed mild laxity compared with the contralateral side. The mean VAS for pain perception decreased from 3.7 to 0.8 (P = 0.001). The modified Mayo wrist (P = 0.001) and Quick DASH (P = 0.001) scores showed significant functional improvement. No surgery-related complications occurred. The present study shows that arthroscopic one-tunnel transosseous repair is a good treatment strategy for TFCC foveal tears in terms of reliable pain relief, functional improvement, and re-establishment of DRUJ stability.

Biomechanical Comparison of Open and Arthroscopic Transosseous Repair of Triangular Fibrocartilage Complex Foveal Tears: A Cadaveric Study

To biomechanically compare the stability between open repair and arthroscopic transosseous repair technique for reattachment of the foveal triangular fibrocartilage complex (TFCC). We also evaluated the feasibility of a new aiming device for the creation of 2 bone tunnels simultaneously during the arthroscopic technique. Six matched pairs of fresh-frozen forearm cadaver specimens were prepared for testing. Group I specimens were treated by open repair with suture anchor. Group II specimens were treated by arthroscopic transosseous suture with a new aiming device. Before and after disruption of the TFCC fovea and after its repair, dorsal and palmar translation of the ulna was measured in both groups in response to a load (3kg) applied in the palmar and then in the dorsal direction. The total translation of the ulna was calculated as the sum of the mean dorsal and palmar translations. The mean total ulnar translation before and after TFCC disruption, and after TFCC repair was 5.94 ± 2.16mm, 9.08 ± 2.64mm, and 6.04 ± 2.18mm, respectively. The specimens demonstrated a significant increase in the total translation of the ulna after disruption of the ulnar attachment of TFCC (P= .003), whereas a significant decrease was observed after TFCC foveal repair (P= .003). The median percentage of eliminated translation after TFCC repair was 64% and 172%, respectively, in groups I and II (P= .043). The athroscopic transosseous suture technique demonstrated superior repair efficacy to the open repair technique in terms of biomechanical strength. This cadaveric study also demonstrated the feasibility of a new aiming device. When making decisions about TFCC foveal repair, arthroscopic transosseous suture technique may provide better biomechanical strength than the open repair technique.