A Ten Year Retrospective Study

E. S. Bittar, P. C. Dell

University of Florida

Department of Orthopaedics

Address correspondence to

Edward S. Bittar, M.D., Ph.D.

5200 Babcock St. N.E.

Palm Bay, FL. 32905

Abstract:

Arthroscopic wrist surgery was performed on 175 patients from 1986 to 1990. A tear of the articular disc (AD) of the triangular fibrocartilage complex was demonstrated arthroscopically in 84 wrists (48%). Arthroscopic excision of the central portion of the torn AD was performed on the wrists of 84 patients.

Thirty-five of the 84 (42%) patients with AD tears were available for follow-up evaluation ten years after arthroscopic excision of the torn AD. Three post-operative features were evaluated: persistent ulnar wrist pain, range of motion and altered function or sensibility.

Two subgroups of AD tears were identified: Isolated AD tears which had no other associated pathology, and Complex AD tears which were associated with ulnocarpal abutment, intracarpal ligament tears and articular cartilage damage to the lunate and distal ulna.

In 20 of 35 wrists, isolated tears of the AD were identified arthroscopically and the central portion of the torn AD resected arthroscopically. Arthroscopic debridement of isolated tears yielded a total of 90% good or excellent results (18 of 20), including 65% excellent results (13 of 20) and 25 % good results (5 of 20). There were no poor results in this subgroup.

In contrast, none of the patients with complex AD tears obtained an excellent result after simple debridement, while only 26% (4 of 15) good results were obtained after excision of complex tears of the AD. Patients with complex tears were unimproved with a fair result in 66% of cases (10 of 15) or were more symptomatic and were considered to have obtained a poor result in 20% of cases (3 of 15) when AD tears were associated with positive ulnar variance or intercarpal ligament tears. None of the patients with a complex AD tear that underwent AD excision had an excellent result.

Arthroscopic management of triangular fibrocartilage complex pathology is a reliable diagnostic and therapeutic treatment option with minimal morbidity and rapid return of function. Treatment of isolated tears of the AD with simple excision in 90% of cases resulted in relief of ulnar wrist pain, increased range of motion and improved function. Positive results obtained with isolated tears do not appear to diminish significantly over a ten-year period compared with five-year results.

Treatment of AD tears that are associated with ulnocarpal abutment, positive ulnar variance and intercarpal ligament tears, in general, have a fair or poor outcome if managed only with arthroscopic excision of the central portion of the torn AD. Results with complex AD tears diminish with time. Pre-operative evaluation should include ulnar variance x-ray views with grip in neutral, full supination and full pronation to rule out ulnocarpal abutment and intercarpal ligament tears.

Introduction:

Wrist arthroscopy was initially described by Chen in 1979 (1) and Watanabe in 1985 (2), but was not popularized until 1986 when arthroscopic surgical techniques for the wrist were described by Roth and Haddad (3) and by Whipple, et. al. (4) and later by Bora , et al. (5) and Botte, et. al. (6). Over the past ten years, diagnostic wrist arthroscopy has evolved to replace arthrography as the “gold standard” for the diagnosis of wrist pathology (7). Arthroscopic surgical techniques have simultaneously developed since 1986 for the management of wrist pathology (8). Few studies of the long-term results of arthroscopic wrist surgery, particularly the management of articular disc (AD) tears, however, have been reported (9).

Since 1986, at the University of Florida, we have been studying the effectiveness of arthroscopic management of ulnar wrist pain caused by tears of the triangular fibrocartilage, a roughly, triangular-shaped fibrocartilage articular disc that attaches to the articular surface of the radius (10). The AD provides stability to the radiocarpal joint and aids in the distribution of axial loads across the joint (11). Under tortional and compressive loads the AD will tear, often within two or three millimeters from the articular surface of the radius where it is attached to the radius by a series of short fibers (12). Many isolated tears of the AD treated in this study were observed to occur at the interface between the AD and the articular surface of the distal radius.

The purpose of this paper is to review our fourteen-year experience with arthroscopic management of tears of the AD of the triangular fibrocartilage complex (TFCC) and to assess whether arthroscopic excision of the AD is a reliable long-term treatment option for the management of ulnar wrist pain caused by a torn AD.

Materials and Methods:

Arthroscopic wrist surgery was performed on one hundred and seventy-five patients from 1986 to 1990. Patients usually presented with chronic ulnar wrist pain. Fifty-five percent of the patients were male. The study group had a mean age of 38 years (range: 17 years to 68 years).

All patients underwent a pre-operative series of plain x-rays, including stress x-rays, and a series of ulnar variance views in neutral, in full pronation and in full supination. In addition, all patients underwent a double injection arthrogram and in selected cases a triple injection arthrogram while extravasation of contrast was monitored (13 and 14).

Finger traps with five to seven pounds of weight were used to distract the wrist. A pump was not used. Instead, a pneumatic transfusion pressure cuff delivered normal saline into the radiocarpal joint through the arthroscope sheath.

Two dorsal arthroscopic portals were utilized. A radial portal was initially established between the third and fourth extensor compartments using a blunt obturator after careful spreading of soft tissues. The radial portal was used primarily for visualization. A 2.3 mm, 30 degree arthroscope was used to visualize the radiocarpal space. An ulnar portal was established under arthroscopic control on the radial side of the extensor carpi ulnaris and was used primarily to introduce tools for excision of the central portion of the AD and to visualize the radiocarpal space from an ulnar perspective. Following AD excision, the resected edge of the AD, the volar and dorsal ulnocarpal ligaments and the lunotriquetral joint were best visualized from the ulnar portal.

Post-operatively, a soft dressing allowed immediate, unrestricted range of motion. Patients were treated by a hand therapist and supervised therapy was initiated by the second or third post-operative day. Sutures were removed one week post-operatively.

A tear of the AD of the TFCC was demonstrated arthroscopically and the central portion of the AD was excised under arthroscopic visualization in eighty-four wrists. Forty-six of the eighty-four (55%) patients with AD tears were available a minimum of ten years later for follow-up evaluation.

Three post-operative features were evaluated: persistent ulnar wrist pain, range of motion and altered function or sensibility. Patients were rated as having an excellent result if all parameters were considered normal. Patients with a good result had all of their ulnar pain relieved with no significant functional deficit. Patients with a fair result had mild to moderate persistent ulnar wrist pain with only moderate improvement and function. Patients were considered to have had a poor result if no significant improvement was noted or if patients were worsened post-operatively.

Results:

From 1986 to 1990 patients with chronic wrist pain underwent arthroscopic evaluation where a substantial number of them were noted to have a torn articular disc (AD). Two subgroups of AD tears were identified: isolated AD tears which had no other associated pathology, and complex AD tears which were associated with ulnocarpal abutment, intracarpal ligament tears and articular cartilage damage to the lunate and distal ulna. Complex AD tears were usually found in patients whose preoperative Xrays demonstrated positive ulnar variance. The results of arthroscopic treatment of isolated and complex TFC tears were compared. Favorable results in both subgroups did not diminish with time.

In twenty-six wrists, isolated linear tears of the AD were identified 1-2 mm off the radial attachment of the AD. Twenty-six isolated tears were treated with excision of the central portion of the torn AD. In these twenty-six patients with avulsion tears of the AD from the radius, good (6 of 26) or excellent (16 of 26) results were obtained after arthroscopic debridement of the AD in 85% of wrists (22 of 26). None of the patients in this subgroup obtained a poor result following excision of the torn AD.

Discussion:

From 1986 to 1990 patients with chronic wrist pain underwent arthroscopic evaluation where a substantial number of them were noted to have a torn articular disc (AD). Two subgroups of AD tears were identified: isolated AD tears which had no other associated pathology, and complex AD tears which were associated with ulnocarpal abutment, intracarpal ligament tears and articular cartilage damage to the lunate and distal ulna. Long-term results of excision of the torn AD was related to the configuaration fo the tear pattern and to the amount of associated intraarticular pathology.

In general, arthroscopic management of TFCC pathology is a reliable diagnostic and therapeutic treatment option with minimal morbidity and rapid return of function. However, patients with AD tears associated with intra-articular pathology, including ulno-carpal abutment, intrinsic carpal ligament tears and chondral damage of the lunate and distal ulna, generally do not appear to have long-term benefit from arthroscopic debridement of a torn AD. In many cases, patients with complex AD tears that undergo simple arthroscopic debridement without reconstruction do poorly. In contrast, the arthroscopic debridement of isolated tears of the AD, in general, provided long-term benefits. Treatment of isolated tears of AD with simple excision in 85% of cases resulted in relief of ulnar wrist pain, increased range of motion and improved function.

Favorable results do not appear to diminish over a ten-year time period. Treatment of complex AD tears that are associated with ulnocarpal abutment, positive ulnar variance and intercarpal ligament tears, in general, have a fair or poor outcome if managed only with arthroscopic excision of the central portion of the torn AD.

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