Aims. Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC. Methods. A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function. Results. A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low. Conclusion. Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC. Cite this article: Bone Jt Open 2021;2(11):981–987

There is a difference of opinion regarding the usefulness of MR Imaging as a diagnostic tool for triangular fibrocartilage complex (TFCC) tears in the wrist. Our aim was to determine the accuracy of direct magnetic resonance arthrography (MRA) in the diagnosis of triangular fibrocartilage complex (TFCC) tears of the wrist in a district general hospital setting. In a retrospective review of 21 patients who presented with complains of wrist pain and following a clinical examination, all had direct MR arthrography of the wrist in our hospital in a 1.5Tesla scanner. All had a diagnostic arthroscopy within 2-4 months of the MR scan. All patients had chronic ulnar sided wrist pain, although only two had a definite history of trauma. The findings of each diagnostic method were compared, with arthroscopy considered the gold standard. Twenty-one patients were studied (10 male: 11 female), mean age 42 years (range 27-71) years). Seventeen TFCC tears were diagnosed on arthroscopy. For the diagnosis of TFCC tears MRA had a sensitivity, specificity and accuracy of 67%. Our results echoed the opinion of some of the previous investigators with an unacceptable sensitivity or specificity for a diagnostic tool. MR arthrography needs to be further refined as a technique before it can be considered to be accurate enough to replace wrist arthroscopy for the diagnosis of TFCC tears. Other centres have reported better accuracy, using more advanced MRI technology. Until this iswidely available at all levels of healthcare the results of MRI for the diagnosis of TFCC tears should be interpreted with caution

Purpose: The purpose of this study was to evaluate the long-term results of arthroscopic treatment in patients affected by triangular fibrocartilage complex (TFCC) type 1b lesions associated with distal radio ulnar joint (DRUJ) instability. Method: 138 patients affected by TFCC type 1b lesions: Group A (117 patients, 27±7 yrs) were treated using an out-in arthroscopic technique and Group B (21 patients, 24±4 yrs) with an associated total DRUJ instability, were treated using an out-in arthroscopic technique in addition to an anchor placement. Inclusion criteria were: TFCC tears, type 1b lesions and no previous wrist fractures. SF-36, DASH, VAS, and ROM were accessed preoperatively and at four years follow-up. Results: All the patients have a significant improvement in terms of SF-36 (p0.05). Conclusion: Arthroscopy is a tool of paramount importance in both diagnosis and treatment of TFCC injuries even associated with DRUJ. Furthermore, type 1b lesions associated with total DRUJ instability should be managed combining an out-in arthroscopic technique with the use of an anchor to completely relieve pain and restore wrist function

Summary. When a TFCC tear is diagnosed, practitioners should maintain a high level of suspicion for the presence of a concomitant SL or LT ligament tear. Introduction. Disruption of the scapholunate (SL) or lunotriquetral (LT) ligament leads to dorsal and volar intercalated segment instability, respectively, while triangular fibrocartilage complex (TFCC) tears result in distal radioulnar joint (DRUJ) instability. Viegas et al. (1993) demonstrated that 56% of grossly visualised cadaveric wrists had one or more tears of a ligament or of the TFCC. The purpose of this investigation is to quantify the incidence, distribution, and correlation of SL, LT, and TFCC tears in a large group of cadaver wrists using magnetic resonance imaging (MRI). Additionally, statistical analysis was performed to predict. Methods. Spin density weighted, fat suppressed, and STIR MRI scans of the wrist were obtained in 48 fresh frozen cadaver arms using a 3 Tesla MRI scanner. The scans were scrutinised by one of us (PC) – a board certified musculoskeletal radiologist. The dorsal, volar, and membranous portions of the SL and LT ligaments were examined sequentially for the presence of a tear. Similarly, the central disk and radioulnar attachments of the TFCC were inspected for tears. Results. A ligament or the TFCC was labeled as torn if there was a complete tear, partial tear, or perforation of one or more of its components, but not if sole degenerative changes, thinning, or fraying of the fibers was observed. Four of the 48 images could not be interpreted due to unsatisfactory scans. The most prevalent injury was a TFCC tear, which was present in 28 (64%) of the 44 wrists examined. SL ligament tears were discovered in 20 (45%) of the wrists, and LT tears were present in 14 (32%) of the wrists. Moreover, 45% of the wrists examined had a TFCC tear and either a SL or LT ligament tear. Specifically, 50% of the 28 wrists with a TFCC tear had a concomitant LT tear, and 46% had a concomitant SL tear. Discussion. SL, LT, and TFCC tears were found in a substantial portion of the wrists examined. Moreover, the majority of wrists with a TFCC tear also had a SL or LT ligament tear. Viegas et al. found that 70% of wrists with a TFCC perforation also had a LT ligament tear. In our series, 71% had a TFCC tear, and 50% of those had a concomitant LT tear

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

Introduction. We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard. Methods. We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated. Results. Two hundred and thirty four (234) MRA were performed over the study period. Fifty patients (50), who subsequently underwent 51 wrist arthroscopies (one bilateral), were included. The mean age was 35 years (range 16–64 years). The average delay between MRA and arthroscopy was 4.8 months (median 4 months, range 17 days–18 months). All patients were symptomatic with wrist pain. At arthroscopy, 26 TFCC tears, 7 SLL tears and 3 LTL tears were found. For TFCC, sensitivity was 96%, specificity 88%, PPV 89% and NPV 96%. For SLL, the values were 57%, 66%, 21% and 91% respectively. For LTL, 67%, 79%, 17% and 97%, respectively. Receiver Operating Characteristic (ROC) curve analysis showed that MRA only reliably differentiates between patients with and without TFCC tears (Area Under Curve AUC = 0.92, p < 0.0001) but not SLL (AUC = 0.62, p=0.28) or LTL (AUC = 0.73, p=0.17) tears. Conclusion. MRA is a sensitive and specific imaging modality for diagnosing TFCC tears. However, the diagnostic accuracy for SLL and LTL tears was not satisfactory. Wrist arthroscopy remains the gold standard if there is a clinical suspicion of inter-carpal ligament tears

The triangular fibrocartilage complex (TFCC) is a known stabiliser of the distal radioulnar joint (DRUJ). An injury to these structures can result in significant disability including pain, weakness and joint stiffness. The contribution each of its components makes to the stability of the TFCC is not well understood. This study was undertaken to investigate the role of the individual ligaments of the TFCC and their contribution to joint stability. The study was undertaken in two parts. 30 cadaveric forearms were studied in each group. The ligaments of the TFCC were progressively sectioned and the resulting effect on the stability of the DRUJ was measured. A custom jig was created to apply a 20N force through the distal radius, with the ulna fixed. Experiment one measured the effect on DRUJ translation after TFCC sectioning. Experiment two added the measurement of rotational instability. Part one of the study showed that complete sectioning of the TFCC caused a mean increase in translation of 6.09(±3) mm. Sectioning the palmar radioulnar ligament of the TFCC caused the most translation. Part two demonstrated a change in rotation with a mean of 18 (± 6) degrees following sectioning of the TFCC. There was a progressive increase in rotational instability until the palmar radioulnar ligament was also sectioned. Linear translation consistently increased after sectioning all of the TFCC ligaments, confirming its importance for DRUJ stability. Sectioning of the palmar radioulnar ligament most commonly caused the greatest degree of translation. This suggests injury to this ligament would more likely result in a greater degree of translational instability. The increase in rotation also suggests that this type of instability would be symptomatic in a TFCC injury

Ulnar shortening osteotomy (USO) is a procedure performed to alleviate ulnar sided wrist pain caused by ulnar impaction syndrome (UIS) and/or triangular fibrocartilage complex (TFCC) injury. Presently, non-union rates for ulnar shortening osteotomy is quoted to be 0–18% in the literature. However, there is a dearth of literature on the effect of site of osteotomy and plate placement on the rate of complications like a delayed union, symptomatic hardware and need for second surgery for hardware removal. In this study, we performed a multi-centered institutional review of ulnar shortening osteotomies performed, focusing on plate placement (volar vs. dorsal) and osteotomy site (distal vs. proximal) and determining if it plays a role in reducing complications. This study was a multi-centered retrospective chart review. All radiographs and charts for patients that have received USO for UIS or TFCC injury between 2013 and 2017 from hand and wrist fellowship-trained surgeons in Calgary, Alberta and Winnipeg, Manitoba were examined. Basic patient demographics including age, sex, past medical history, and smoking history were recorded. Postoperative complications such as delayed union, non-union, infection, chronic regional pain syndrome, hardware irritation requiring removal were evaluated with a two-year follow-up period. Osteotomy sites were analyzed based on the location in relation to the entire length of the ulna on forearm radiographs. Surgical techniques including volar vs. dorsal plating, oblique vs. transverse osteotomy cuts, and plate type were documented. Continuous variables of interest were summarized as mean or medians with standard deviation or inter-quartile range as appropriate. Differences in baseline characteristics were determined by t-test or one-way ANOVA for continuous variables and chi-square or Fischer exact test for dichotomous variables. All analyses were conducted using SPSS V24.0 (Chicago, IL, USA). All statistical tests were considered significant if p < 0.05. Between 2013–2017 there were 117 ulnar shortening osteotomies performed. The average age of patients was 46.2 ± 16.2, with 62.4% being female. The mean pre-operative ulnar variance was +3.89 ± 2.17 mm and post-operative ulnar variance was −1.90 ± 1.80 mm. 84.6% of the plates were placed on the volar aspect of the ulna and 14.5% were placed on the dorsal aspect. An oblique osteotomy was made 99.1% of the time. In measuring osteotomy placement, the average placement was made in the distal 1/3 of the ulna. Overall, there was a 40% complication rate. Hardware irritation requiring removal encompassed 23%, non-union 14%, and wound infection covered 0.8%. When comparing dorsal vs volar plating, there was no statistically significant difference for non-union or hardware removal. Similarly, in evaluating osteotomy level, there was no statistical difference between proximal vs distal osteotomy for non-union and hardware removal. In this multi-centered retrospective review of ulnar shortening osteotomies, we found that there was an overall complication rate of 40%. There was no statistically significant difference in complication rates between dorsal vs volar plate placement or proximal vs distal osteotomy sites. Further studies examining other potential risk factors in lowering the complication rate would be beneficial

Aim. This study reviewed the efficacy of a CT arthrogram in clinical decision making for wrist disorders. Methods. Sixty four consecutive CT arthrograms done in a three year period at Glenfield Hospital were selected. All patients were referred by hand consultants at the Glenfield Hospital and all investigations were performed by a single senior musculoskeletal radiologist. CT arthrograms focussed on the following areas: scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), peripheral and central triangular fibrocartilage complex (TFCC) tears, and articular surface disorders. Referral and clinic letters for all patients were obtained. We collected patient demographic detail, prescan diagnosis and clinical plan, CT arthrogram findings, postscan diagnosis and clinical plan and the final outcome. A decision was made whether the scan helped in the clinician's management plan and if so how it helped. Results. There were 35 male and 29 female patients with a mean age of 44.1 years. The right wrist was involved in 42 and the left in 22 patients. Sixty three of the 64 patients had their management based on the CT scan. In 54 of these the CT arthrogram either confirmed and calibrated the diagnosis or identified a new diagnosis. In 10 patients the scan was normal and allowed patient reassurance. Thirty six patients had ulnar sided problems, 20 had radial sided disorders and eight had midcarpal abnormality. The most common abnormality noted was a TFCC tear (24). The next most common was chondral damage/arthritis (14) followed by scapholunate interosseous ligament tear (12). The diagnosis was either confirmed and its extent established (31) or identified in addition to the primary diagnosis (19). Conclusions. The CT arthrogram is a helpful tool in the management of intra-articular wrist pathology. We found it to be useful in both confirming and calibrating the diagnosis and also diagnosing occult patho

Introduction. Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods. We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results. The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion. The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure

Purpose of the study. To evaluate the changes of the wrist by arthroscopy without distraction in patient with multiple hereditary osteochondromatosis (MHO) and enchondromatosis in relation to the forearm deformity and the combination with following surgical procedure. Introduction. Wrist arthroscopy was used to evaluate the changes in the wrist in patients with MHO and enchondromatosis and to correlate these changes to specific deformities of the forearm bones. Material and Methods The new technique of wrist arthroscopy without distraction was used in 16 children in 20 wrist joints, with MHO (12 patients) and enchondromatosis (4 patients). Conventional 2.4mm arthro-scope and the III/IV, VI/R and MCU approaches were used in combination mostly with the following surgical procedures according to present deformities (15 times). The arthroscopical findings were correlated to the conventional X-ray examinations of the wrist (radial articular angle, carpal slip, and relative ulna shortening). Results. 1. Wrist arthroscopy without distraction offers the sufficient information about wrist anatomy in children and it was possible to continue with the surgical procedure in the same session. 2. The arthroscopic findings in the radiocarpal and mediocarpal space were normal in all wrist joints, with exception of one patients with cartilage lesions. 3. The articular disc of triangular fibrocartilage complex failed in 11 wrists, where shortening of the ulna was present or head of ulna was not centred to incisura radii. 4. The normal or reduced disc was found in 5 and 4 wrists, respectively, where ulna was not shortened or where normal position of head of ulna was re-established after lengthening. No correlation was obtained between discus anatomy and radial articular angle and carpal slip. Conclusions. Shortening of the ulna by MHO or encho-dromatosis leads to elimination of the articular disc and later to degenerative changes in wrist joint. Lengthening of the ulna to distal radioulnar joint leads probably to re-establishment of the articular disc. Arthroscopy without distraction evaluates the wrist conditions and the results of treatment and enables a surgical procedure in the same session in children of the school age

Purpose: The purpose of this study is to investigate the external and internal vascular anatomy of the lunate bone. The genesis of lunatomalacia requires some combination of load, vascular risk and mechanical predisposition. The findings will be correlated with the major existing theories of the cause of lunatomalacia and the most frequent fractures associated with Kienbocks disease: transverse shear fracture and midcoronal fracture. Material and methods: We studied 21 cadaver upper limbs using latex injection and Spalteholz technique. We investigated the extra- and intraosseous blood supply. In 17 wrists we evaluate the incidence and distribution of anatomic features, arthrosis, and soft tissue lesions. Results: The lunate morphology was 5 Type I (29.4%), 11 Type II (64.7%) and 1 Type III (5.9%). The lunate was found to have a separate facet for the hamate in 47.1% (Size 3–6 mm). Most frequent arthrosis was identified in the radius (88.2%) and lunate (94.1%). The triangular fibrocartilage complex (TFCC) was found torn in 47%, the lunotriquetral interosseous ligament (LTIL) was torn in 23.5%, and the scapholunate interosseous ligament (SLIL) was torn in 53% of the wrists. Statistical analysis found a correlation between the presence of arthrosis at the proximal pole of the hamate and the presence of a lunate facet. There was also a correlation between the presence of a tear in the SLIL and the presence of cartilage erosion in the scaphoid (p= 0.002). Arthrosis on the lunate was found to have a correlation with an SLIL tear or TFCC tear. The nutrient vessels entered the lunate throught the dorsal and volar poles in all the specimens. Dorsal vessels enter the bone through one or two foramina in the proximal, ulnar, and nonarticular aspect of the bone. Two to six nutrient vessels were observed entering the volar pole throught a ligament insertion: radioscapholunate ligament of Testut-Kuentz, radio-lunate-triquetrum ligament and ulnar-lunate-triquetrum ligament. Conclusions: The lunate had consistent dorsal and palmar arteries entering the bone in all the specimens. The supply blood and foramina number is more important in the volar pole of the lunate than the dorsal pole. The vascular patterns support a theory of compression fracture from repeated trauma, or anatomical predispositions as the most likely cause of Kienbocks disease

Purpose: This in-vitro study examined the effect of simulated Colles fractures on load transmitted to the distal ulna, using an in-line load cell. Our hypothesis was distal radial fracture malposition will increase distal radial ulnar joint (DRUJ) load relative to the native position of the radius. Method: Eight fresh frozen upper-extremities were mounted in a motion simulator which enabled active forearm rotation. An osteotomy was performed just proximal to the distal radioulnar joint, and a 3-degree of freedom modular appliance was implanted which simulated Colles type distal radial fracture deformities. This device allowed for accurate adjustment of dorsal angulation and translation (0, 10, 20 and 30 degrees dorsal angulation and 0, 5 and 10mm dorsal translation both isolated and in combination). A 6-DOF load cell was inserted in the distal ulna 1.5 cm proximal to the ulnar head to quantify DRUJ joint forces. Distal ulnar loading was measured following simulated distal radial deformities with both an intact and sectioned triangular fibrocartilage complex (TFCC). Results: The maximum resultant transverse distal ulnar load occurred during active forearm pronation and supination. Increasing magnitudes of dorsal angulation and translation of the distal radius increased loading in the distal ulna. For pronation with the ligaments intact, the transverse resultant load for the non-fracture, native positioning was significantly lower (p< 0.05) than the majority of malpositioned cases except for the translations only (not combined with angulation). However, all fracture orientations for supination had an increased effect on the resultant loading (p< 0.05) when ligaments were intact. Greater forces were measured in the distal ulna when the TFCC intact relative to TFCC sectioning. Sectioning the TFCC eliminated the effect of fracture malposition for both pronation and supination. The range of maximum transverse force for intact pronation and supination was between 118& #61617;34N and 130& #61617;39N, respectively. Similarly, for sectioned pronation and supination, the maximum transverse forces were and 93& #61617;40N and 89& #61617;24N, respectively. Conclusion: Malpositioning of distal radial fractures in dorsal translation and angulation was found to increase forces in the distal ulna, which may be an important source of residual pain following malunion of Colles fractures. Healing of the distal radius in an anatomic position resulted in the least forces. Sectioning the TFCC released the tethering effect of the radius on the ulna, decreasing DRUJ force. This is the first study of its kind to attempt to quantify the forces at the DRUJ as a result of Colles fractures, and these early findings provide important baseline information related to the biomechanics of the DRUJ

Aims

The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.

Aims

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

Aims

To determine the role of early MRI in the management of suspected scaphoid fractures.

Aims

To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention.