Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain

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1 WRIST AND HAND Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain T. Nishizuka, M. Tatebe, H. Hirata, T. Shihara, M. Yamamoto, K. Iwatsuki From Nagoya University Graduate School of Medicine, Nagoya, Japan The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 3 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36. months (15 to 54). Significant differences in Hand2 score at 18 months were evident between the USO group and TFCC debridement group (p =.3), and between the TFCC repair group and TFCC debridement group (p =.29). Within-group comparisons showed that Hand2 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did t decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but t in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulcarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement. Cite this article: Bone Joint J 213;95-B: T. Nishizuka, MD, Orthopaedic Surgeon M. Tatebe, MD, PhD, Orthopaedic Surgeon H. Hirata, MD, PhD, Professor T. Shihara, MD, PhD, Orthopaedic Surgeon M. Yamamoto, MD, PhD, Orthopaedic Surgeon K. Iwatsuki, MD, PhD, Orthopaedic Surgeon Nagoya University Graduate School of Medicine, Department of Hand Surgery, 65 Tsurumai-Cho, Showa-Ku, Nagoya , Japan. Correspondence should be sent to Dr T. Nishizuka; nishizuka@med.nagoya-u.ac.jp 213 The British Editorial Society of Bone & Joint Surgery doi:1.132/31-62x.95b $2. Bone Joint J 213;95-B: Received 28 February 213; Accepted after revision 21 August 213 Various and ambiguous pathological mechanisms can result in ulnar wrist pain, 1,2 which can leave the preferred treatment to personal preference of the clinician rather than diagstic criteria. Treatment options consist of debridement of the triangular fibrocartilage complex (TFCC), 3 open or arthroscopic repair of the TFCC, 4 resection of the ulnar head, and ulnar shortening osteotomy (USO). 5 In relation to arthroscopic debridement, Minami et al 6 and Osterman 3 reported that good post-operative results were obtained in most patients, but outcomes were only assessed at the final follow-up (mean 36 months (15 to 54)). In contrast, Hulsizer, Weiss and Akelman 5 reported 13 cases of USO after failed arthroscopic TFCC debridement. In that study, 97 patients with central or n-detached ulnar peripheral tears of the TFCC underwent arthroscopic TFCC debridement, 13 of whom experienced persistent pain in the region of the TFCC for more than three months after surgery. All 13 patients underwent USO at a mean of eight months after the failed arthroscopic debridement. In relation to osteoarthritis (OA) of the knee, a review by Laupattarakasem et al 7 showed that arthroscopic debridement probably did t improve pain or functional ability compared with placebo (sham surgery) and concluded that arthroscopic debridement was of benefit for OA of the knee. The purpose of the current study was to evaluate the results of arthroscopic TFCC debridement for recalcitrant ulnar wrist pain based on our treatment algorithm. We strictly limited the indications for arthroscopic TFCC debridement, and assessed outcomes at one, two, three, four, five, six, eight, ten, 12, and 18 months post-operatively. Our hypothesis was that TFCC debridement has little favourable effect on the clinical course of recalcitrant ulnar wrist pain. Patients and Methods This was a retrospective cohort study of patients with recalcitrant ulnar wrist pain treated by the four hand-surgeons (MT, HH, TS, MY) in our hospital according to a previously discussed and agreed treatment algorithm (Fig. 1). Records of all patients who had been treated between 28 and 21 were collected and all patients received written information about the purpose and procedures of the study. Written and informed consent was VOL. 95-B, No. 12, DECEMBER

2 1688 T. NISHIZUKA, M. TATEBE, H. HIRATA, T. SHINOHARA, M. YAMAMOTO, K. IWATSUKI Ulnar wrist pain Splint for 3 months Not improved Ulnar variance on plain radiographs < 3 mm 3 mm TFCC disc wear perforation flap tear TFCC disc wear perforation flap tear USO DRUJ instability Cartilage grade II grade III grade IV Cartilage grade II grade III grade IV USO + TFCC repair TFCC detachment from fovea DRUJ instability TFCC repair TFCC debridement Fig. 1 Treatment algorithm for ulnar wrist pain (TFCC, triangular fibrocartilage complex; USO, ulnar shortening osteotomy; DRUJ, distal radioulnar joint). obtained from those patients who answered the questionnaire and participated in the clinical evaluation. Ethical approval for the study was obtained from the institutional review board. A total of 11 patients (11 wrists) with recalcitrant ulnar wrist pain were enrolled. There were 54 men and 47 women with a mean age of 39.4 years (15 to 7). All patients were referred from other hospitals after failed conservative treatment. They all displayed focal tenderness over the ulnar carpal bones, ulnar head or both, and showed positive results to provocative tests 1,2,8 such as the ulcarpal stress test, ulnar fovea sign test, and distal radioulnar joint (DRUJ) instability test. Conservative treatment was performed again for three months at our outpatient clinic during which time patients wore a removable short-arm brace to immobilise the wrist continuously in the neutral position. Symptoms did t improve following three months of conservative treatment in 7 patients. At the completion of planned conservative treatment, we explained the treatment plan based on our algorithm to each patient. A total of 13 patients declined surgery and wanted to continue conservative treatment, forming the control group. All the remaining patients received surgical treatment. However, four patients declined USO despite definitive findings of ulcarpal abutment syndrome, and instead underwent TFCC debridement. We therefore excluded these four cases from the study. Overall, 66 patients (66 wrists) participated in this study including the 13 conservatively treated patients. Patient demographics, including age, gender, workers compensation status and symptom duration were collected from these patients for analysis. There were 36 males and 3 females, a mean age at the end of conservative treatment of 38.1 years (15 to 67). The dominant side was affected in 5 patients. The mean duration of follow-up was 36. months (15 to 54). A series of wrist radiographs were obtained in a standardised position to assess carpal alignment using the wrist support developed by Nakamura et al. 9 A posteroanterior radiograph of the wrist was obtained with the shoulder in 9 of abduction, the elbow in 9 of flexion, the forearm in neutral rotation, and the wrist in neutral alignment. Ulnar variance was measured to the nearest 1 mm using the method of perpendiculars. 1 In addition, plain radiographs were scrutinised for evidence of cystic changes by two authors (TN, KI). Results of pre-operative MR imaging were available in all cases. The diagsis was made from the MRI using diagstic criteria for ulcarpal abutment syndrome, as previously reported. 11 Briefly, the presence of decreased signal THE BONE & JOINT JOURNAL

3 SIMPLE DEBRIDEMENT HAS LITTLE USEFUL VALUE ON THE CLINICAL COURSE OF RECALCITRANT ULNAR WRIST PAIN 1689 Table I. Ulcarpal abutment syndrome criteria Ulnar variance TFCC disc lesions * Cartilage lesions 3 mm or < 3 mm and * TFCC, triangular fibrocartilage complex (lesions including wear, perforation or flap tear) grades II to IV 17 intensity on T 1 -weighted imaging and increased signal intensity or low signal intensity with spots of increased signal intensity on T 2 -weighted imaging at the ulnar aspect of the lunate and/or radial aspect of the triquetrum and/or ulnar head were carefully ted by two authors (TN, KI). The surgical procedures including arthroscopy were performed under axillary local anaesthetic block in 52 patients and under general anaesthesia in one patient. Instability of the DRUJ was assessed once the anaesthesia had taken its full effect, evaluating DRUJ stability through passive anteroposterior translation of the ulna on the radius, 12 while the forearm was positioned in neutral, full supination, and full pronation. 8 We performed arthroscopy of the wrist in all patients using a 2.3 mm arthroscope for the radiocarpal joint (RCJ) and the midcarpal joint (MCJ) and a 1.9-mm arthroscope for the DRUJ. 13,14 The arthroscope was inserted via the 3-4 portal and the midcarpal radial (MCR) portal and the probe via the 4-5 portal and the midcarpal ulnar (MCU) portal exchanging the portals as necessary. The arthroscopic findings recorded included TFCC lesions (disc tear, perforation of disc, disc wear, foveal tear, etc.), cartilage lesions, joint instabilities and syvitis. We also performed DRUJ arthroscopy with a technique that allowed us to confirm detachment of the TFCC at the fovea. 14 We used one or two portals on the dorsal side of the DRUJ as DRUJ distal and/or proximal portals. The former was located between the ulnar head and the TFCC and the latter between the sigmoid tch of the radius and the ulnar metaphysis. Lutriquetral (LT) ligament tear and LT instability were evaluated through radiocarpal joint (RCJ) and midcarpal joint (MCJ) arthroscopy according to the methods described by Geissler et al. 15 LT stability was checked before and after USO. All procedures were recorded onto high-definition DVD. Arthroscopic findings were routinely documented, citing all intra-articular structural pathology. Syvial lesions were classified according to the method described by Watanabe, Takeda and Ikeuchi, 16 with some modification, and cartilage lesions were classified according to the method described by Beguin and Locker. 17 Disc lesions of the TFCC were classified as wear, perforation or flap-tear according to the method described by Yamamoto et al, 14 with some modification. Diagsis of ulcarpal abutment syndrome was made using the criteria reported by Imaeda et al, 11 with some modification. We placed more emphasis on arthroscopic findings when considering the reported low sensitivity 1 for MRI in this study from the algorithm (Fig. 1). The risk of ulcarpal overload is reportedly high if the ulnar variance exceeds 2.5 mm. 18 We therefore applied stricter diagstic criteria for those patients showing ulnar variance 2 mm. A diagsis of ulcarpal abutment was made if more than one finding was present when ulnar variance was 3 mm. More than two findings were required for the diagsis when ulnar variance was 2 mm (Table I). Surgical treatment was selected according to the treatment algorithm based on arthroscopic findings (Fig. 1). We performed USO according to the methods described by Tatebe et al 19 for those patients who fulfilled the criteria of ulcarpal abutment. A skin incision was made longitudinally along the distal third of the ulna, and extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU) were exposed. Then, we performed two parallel transverse osteotomies using an oscillating saw, and removed approximately 2 mm to 5 mm of bone to match the ulnar variance with the contralateral side. Finally, we fixed the osteotomy site with a five-hole 3.5 mm locking compression plate (LC-LCP; Synthes, Tokyo, Japan) (Fig. 2). We used additional device. Arthroscopy was undertaken both before and after USO in all of the cases. Arthroscopic TFCC repair was to be added if DRUJ instability still existed after USO. Temporary LT fixation with two Kirschner (K-) wires was added percutaneously if LT ligament tear of a Geissler grade IV 15 was present and if LT instability was t corrected after the USO procedure. Those patients with a positive DRUJ instability test and arthroscopically confirmed detachment of the TFCC at the fovea who did t fulfil the diagstic criteria for ulcarpal abutment syndrome were diagsed as having Palmer s type 1B lesion 2 and underwent arthroscopic transosseous TFCC repair. 4,21,22 A longitudinal skin incision approximately 1.5 cm long was made at the ulnar side of the ulnar neck, and the ulna between the ECU and the FCU was exposed. Two osseous tunnels were made by inserting two parallel 1.2 mm K-wires from the ulnar neck to the foveal region under DRUJ arthroscopy. Then, a nylon suture was passed into the joint from the outside through the TFCC via the dorsal osseous tunnel using 18 gauge venepuncture needle. Ather 18- gauge venepuncture needle was inserted with a lasso loop of a 3- nylon suture via the volar osseous tunnel. We retrieved the end of a nylon suture through the lasso loop to enable it to be externalised. The TFCC foveal tear was anchored to the fovea by tying a nylon suture at the proximal entrance of the osseous tunnel (Fig. 3). This procedure creates an anatomical repair of the radioulnar ligament, which rises nearly vertically from the fovea. VOL. 95-B, No. 12, DECEMBER 213

4 169 T. NISHIZUKA, M. TATEBE, H. HIRATA, T. SHINOHARA, M. YAMAMOTO, K. IWATSUKI Fig. 2 Radiographs in a 35-year-old female patient pre-operatively (left), immediately after ulnar shortening osteotomy (middle) and at 1.5 years after ulnar shortening osteotomy (right). Fig. 3 Diagram and arthroscopic images showing repair of the triangular fibrocartilage complex (TFCC). Top left: diagrammatic representation; top right: arthroscopic image showing a nylon suture and a lasso loop of a 3- nylon suture passed into the joint from the outside through TFCC via the osseous tunnel using an 18-gauge venepuncture needle; bottom left: retrieval of the end of a nylon suture through the lasso loop; bottom right: anchoring of the TFCC foveal tear to the fovea by tying a nylon suture at the proximal entrance of the osseous tunnel. We performed TFCC debridement for those with a TFCC lesion other than type 1B, such as a wearing (Palmer s type 2) or a TFCC flap tear (Palmer s type 1A) 2 that did t fulfil the criteria for ulcarpal abutment syndrome and/or TFCC detachment from the fovea. We also performed simple arthroscopic TFCC debridement for those patients with Palmer s type 1B lesion but without apparent DRUJ instability even under anaesthesia. Arthroscopic debridement of the unstable TFCC flap and TFCC fibrillation was performed in a sequence of arthroscopic THE BONE & JOINT JOURNAL

5 SIMPLE DEBRIDEMENT HAS LITTLE USEFUL VALUE ON THE CLINICAL COURSE OF RECALCITRANT ULNAR WRIST PAIN 1691 Fig. 4 Arthroscopic view of the ulnar side of the radiocarpal joint before debridement of the triangular fibrocartilage complex fibrillation and syvitis (left) and after debridement (right). assessment, using the same portals (3-4 and 4-5 portals) with the aid of a side-cutting shaver or ablation system. We also performed syvectomy when local or diffuse syvitis was identified (Fig. 4). We debrided only damaged parts of the disc taking care t to incise the ligamentous portion. After surgery, patients who underwent USO or TFCC repair wore an above-the-elbow cast with the elbow maintained at 9 of flexion, the forearm in neutral rotation, and the wrist in neutral position for four weeks. 19 At four weeks, we removed the K-wires used for LT temporary fixation. Patients who underwent TFCC debridement wore a shortarm brace for a duration of their choosing. Post-operatively patients were asked attend for review every week for the first month and once a month thereafter for at least 18 months. The primary outcome measure was Hand2, a validated patient-rated outcome assessment instrument used to measure upper extremity disability. 23,24 The penultimate item of Hand2 is the pain score. Patients were asked to fill out Hand2 independently before medical examination at each visit. The secondary outcome measure was grip strength, as measured using a dynamometer on the injured and contralateral sides. This allowed results to be expressed as a percentage of the contralateral data for rmalisation. Hand2, pain score, grip strength, and range of movement (dorsal and palmar flexion of the wrist, and pronation and supination of the forearm) were assessed one day before surgery and once a month for up to 18 months postoperatively. Statistical analysis. Analysis of variance (ANOVA) was used for comparison of pre-operative and 18 months postoperative demographic data, Hand2 score, pain score, percentage grip strength, LT joint instability and range of movement between the four groups. A chi-squared test was used for comparison of female rate, radiological findings, TFCC and cartilage arthroscopic findings. We performed multiple comparisons of the four treatment groups using the Bonferroni test when significant differences were detected. Student s t-test was used for comparison of preoperative Hand2 scores, pain scores, percentage grip strength, and range of movement with those at each month of post-operative follow-up within each group. A p-value <.5 were considered significant. Missing values were circumvented using the method kwn as the last-observation-carried-forward method, 25 which assumes that the outcome remained constant at the last observed value after dropout. Results Patients demographic data were comparable among all four groups, except for the increased proportion of females in the USO group (Table II). Mean ulnar variance was largest in the USO group and decreased in the order of conservative treatment, TFCC debridement, and TFCC repair groups, respectively (Table II). Statistical analysis indicated a significant difference in mean ulnar variance between the USO group and TFCC repair (), TFCC debridement groups () and conservative groups (p =.5; all Bonferroni multiple comparison test). A significant difference was seen between the USO group and the other two surgically treated groups in regard to TFCC and cartilage lesions (Table III). The ratio of patients with ulnar variance 3 mm was significantly higher in the USO group as compared with the other two surgically treated groups. In four of the 13 patients in the conservative VOL. 95-B, No. 12, DECEMBER 213

6 1692 T. NISHIZUKA, M. TATEBE, H. HIRATA, T. SHINOHARA, M. YAMAMOTO, K. IWATSUKI Table II. Patient demographic data Procedure * USO TFCC repair TFCC debridement Conservative n Mean age (yrs) (range) 4.3 (17 to 69) 3.4 (15 to 67) 38.3 (24 to 62) 42.5 (24 to 64) Female (n, %) 19 (79) 5 (33) 5 (36) 2 (15) Mean symptom duration (mths) (range) 7.5 (4 to 15) 7.4 (4 to 14) 8.2 (3 to 18) 8.5 (3 to 18) Workers compensation (n, %) 3 (13) 2 (13) 2 (14) 4 (31) Mean ulnar variance (mm) (range) 3.1 (1 to 7).2 (-1 to 3).7 ( to 3) 1.5 ( to 5) * USO, ulnar shortening osteotomy; TFCC, triangular fibrocartilage complex significant difference between USO group and TFCC repair (p =.12)/TFCC debridement (p =.6)/conservative treatment (p <.1) groups (Bonferroni multiple comparison test) significant difference between the USO group and TFCC repair ()/TFCC debridement ()/conservative treatment (p =.5) groups (Bonferroni multiple comparison test) Table III. Triangular fibrocartilage complex (TFCC) disc and cartilage arthroscopic findings for each surgically treated group, and ulnar variance (UV) distribution and ulcarpal abutment (UCA) in all four groups Findings at arthroscopy (n, %) TFCC disc lesions Cartilage lesions (grade) Wear Perforation Flap tear Total II III IV Total UV 3 mm on x-ray (n, %) Positive UCA (n, %) USO (n = 24) 15 (63) 5 (21) 2 (8) 22 (92) * 6 (25) 9 (38) 7 (29) 22 (92) 14 (58) 24 (1) TFCC repair (n = 15) 5 (33) () () 5 (33) 5 (33) () () 5 (33) () () TFCC debridement (n = 14) 2 (14) 1 (7) 1 (7) 4 (29) 2 (14) () 2 (14) 4 (29) () () Conservative treatment (n = 13) (23) Unclear * significant difference in the rates of total TFCC disc lesions between the ulnar shortening osteotomy (USO) group and TFCC repair () / TFCC debridement () groups (Bonferroni multiple comparison test) significant difference in the rates of total cartilage lesions between the USO group and TFCC repair () / TFCC debridement () groups (Bonferroni multiple comparison test) significant difference in the rates of ulnar variance 3 mm between the USO group and TFCC repair () / TFCC debridement () / conservative treatment (p =.38) groups (Bonferroni multiple comparison test) significant difference in the rates of positive UCA between the USO group and TFCC repair () / TFCC debridement () / conservative treatment () groups (Bonferroni multiple comparison test) Table IV. Syvitis distribution in each group (USO, ulnar shortening osteotomy; TFCC, triangular fibrocartilage complex) Syvitis (n, %) Treatment Normal Local Diffuse USO (n = 24) 1 (4) 1 (42) 13 (54) * TFCC repair (n = 15) 4 (27) 1 (67) 1 (6) TFCC debridement (n = 14) () 3 (21) 11 (79) * Conservative treatment (n = 13) * significant difference (p <.5) in the rate of diffuse syvium between the USO group and TFCC repair group (p =.4), and between the TFCC debridement group and TFCC repair group () (Bonferroni multiple comparison test) treatment group the MRI criteria for ulcarpal abutment syndrome were met, although arthroscopic findings were unavailable for this group. Diffuse syvitis was most prevalent in the TFCC debridement group, followed sequentially by the USO group and TFCC repair group (Table IV). A significant difference in the incidence of diffuse syvitis was found between the USO group and TFCC repair group (p =.4), and between the TFCC debridement and TFCC repair group (, Bonferroni multiple comparison tests). Geissler IV lesions were defined as having LT instability: two of 24 patients in the USO group, of 15 in the TFCC repair group, and of 14 patients in TFCC debridement group showed LT joint instability (Table V). Significant differences in Hand2 score were seen between USO and TFCC debridement groups (p =.3), as well as between the TFCC repair group and TFCC debridement group at 18 months (p =.29, Bonferroni multiple comparison test). In addition, a significant difference in pain score was seen between the USO group and THE BONE & JOINT JOURNAL

7 SIMPLE DEBRIDEMENT HAS LITTLE USEFUL VALUE ON THE CLINICAL COURSE OF RECALCITRANT ULNAR WRIST PAIN 1693 Table V. Lutriquetral ligament lesion distribution observed with arthroscopy in each group (USO, ulnar shortening osteotomy; TFCC, triangular fibrocartilage complex) Lutriquetral ligament lesion Normal Geissler I Geissler II Geissler III Geissler IV USO (n = 24) 12 (5) 3 (13) 6 (25) 1 (4) 2 (8) TFCC repair (n = 15) 1 (67) 1 (7) 1 (7) 3 (2) () TFCC debridement (n = 14) 14 (1) () () () () Conservative treatment (n = 13) Unkwn Unkwn Unkwn Unkwn Unkwn Table VI. Mean Hand2 Score, pain score, and percentage grip strength at the time of enrolment and 18 months after enrolment (USO, ulnar shortening osteotomy; TFCC, triangular fibrocartilage complex) Hand2 Pain score % Grip strength Treatment months 18 months months 18 months months 18 months USO 35.4 (2.5 to 83) 8.7 ( to 22) * 5.1 ( to 9) 1.5 ( to 6) * 7.5 (24 to 124) 86. (65 to 121) * TFCC repair 32.2 (7 to 66.5) 1.8 ( to 24.5) * 4.3 (2 to 9) 2.3 ( to 4) 77.2 (31 to 16) 9.3 (68 to 125) * TFCC debridement 36.3 (16 to 7) 25.8 (1 to 56) 4.8 (2 to 1) 3.4 (1 to 5) 68.6 (2 to 117) 74. (17 to 15) Conservative treatment 31.3 (4 to 76) 15.7 (3 to 76) 4.5 (1 to 8) 2.4 ( to 7) 65.6 (24 to 94) 68. (48 to 87) * significant difference between groups for the following variables. Hand2 (18 months): USO/TFCC debridement (p =.3); Hand2 (18 months): TFCC repair/tfcc debridement (p =.29); Pain score (18 months): USO/TFCC debridement (p =.11); % Grip strength (18 months): USO/conservative treatment (p =.17); % Grip strength (18 months): TFCC repair/conservative treatment (p =.18) (all Bonferroni multiple comparison tests) TFCC debridement group at 18 months (p =.11, Bonferroni multiple comparison test) (Table VI). Within-group Hand2 score comparisons revealed a significant decrease at five months or later when compared with that at enrolment in the USO and TFCC repair groups, but significant change in the TFCC debridement or conservative treatment groups (p-values given in Figure 5). Within-group pain score comparisons also revealed a significant decrease at two post-operative months or later when compared with that at enrolment in the USO and TFCC repair groups, but significant change in the TFCC debridement or conservative treatment groups (p-values given in Figure 6). In addition, considerable differences in the patterns of Hand2 scores (Fig. 5) and pain scores (Fig. 6) over time were evident between the USO/TFCC repair groups and the TFCC debridement/conservative treatment groups. Once Hand2 and pain scores reached a significant difference, this improvement tended to be maintained thereafter in the USO/TFCC groups. In contrast, those scores kept fluctuating or seldom reached a significant level of improvement in the TFCC debridement/conservative treatment groups. A significant difference in grip strength was identified between the USO and conservative treatment groups (p =.17), and between the TFCC repair and conservative treatment groups at 18 months post-operatively (p =.18) (Bonferroni multiple comparison test). The USO and TFCC repair groups showed significant improvement at 18 months when compared with values at enrolment within each group (Fig. 7). No significant differences in dorsal (p =.15) or palmar wrist flexion (p =.92), or forearm pronation (p =.552) and supination (p =.197) range of movements were seen between the four groups at 18 months or over time within groups when comparing the enrolment values with the 18 months follow-up values (all Student s t-tests) (Table VII). Recurrent pain was seen in four cases in the TFCC repair group. In the USO group two patients used a low-intensity ultrasound sonic accelerated fracture healing system EXO- GEN, Piscataway, New Jersey) to enhance bone union (one from three to ten months post-operatively and the other from three to 11 months), and cases underwent secondary surgery except for removal of plates. Discussion Accurate diagsis of ulnar wrist pain is difficult, so physicians sometimes deliberate over treatment procedures. Historically, many authors have reported treatment outcomes of arthroscopic TFCC debridement for recalcitrant ulnar wrist pain from TFCC injury. 3,5,6 Osterman 3 reported that as many as 73% of wrists treated with arthroscopic TFCC debridement achieved complete pain relief. Minami et al 6 reported that overall clinical results were excellent in 13 of 16 patients. However, those two studies showed some limitations. First, they did t use numerical pain rating scales and patient-rated outcome tools. In contrast, we used a validated patient-rated outcome assessment and numerical pain rating scales. Second, they assessed outcomes only at final follow-up after surgery. Even if pain and functions improve for a certain post-operative period, symptoms may return over time. We assessed outcomes at one, two, three, four, five, six, eight, ten, 12, and 18 months post-operatively, and followed patients for a mean of 36 months, revealing that patient-rated disability scores for recalcitrant ulnar wrist pain tended to fluctuate over time in the TFCC debridement/conservative treatment groups. VOL. 95-B, No. 12, DECEMBER 213

8 1694 T. NISHIZUKA, M. TATEBE, H. HIRATA, T. SHINOHARA, M. YAMAMOTO, K. IWATSUKI 1 8 USO TFCC repair p =.2 1 p =.1 p =.9 p =.5 p =.22 8 Hand TFCC debridement Conservative treatment 1 p = p =.47 p =.49 8 Hand Follow-up (mths) Fig. 5 Follow-up (mths) Bar charts showing the mean Hand2 scores for the ulnar shortening osteotomy (USO), triangular fibrocartilage complex (TFCC) repair, TFCC debridement and conservative groups. The error bars dete the standard deviation and statistically significant p-values are given (Student s t-test). Third, they did t define the indications for arthroscopic TFCC debridement using a treatment algorithm. The present study used a treatment algorithm to exclude patients with obvious ulcarpal abutment or TFCC detachment from fovea and to strictly limit the indications for arthroscopic TFCC debridement. Our algorithm seems similar to other algorithms reported recently. 26,27 Arthroscopic debridement generally consists of shaving of unstable TFCC flaps, TFCC fibrillation, and redundant syvium. However, arthroscopic debridement by means stops the degenerative process. Hulsizer et al 5 reported that they performed USO after failed arthroscopic TFCC debridement. In their study, 97 patients with central or n-detached ulnar peripheral tears of TFCC underwent arthroscopic TFCC debridement. Ulnar variance was < 2.5 mm in all cases. As a result, 13 of the 97 patients experienced persistent pain in the TFCC region for more than three months after surgery. At a mean of eight months after failed arthroscopic TFCC debridement, all 13 patients underwent USO, and 12 of these achieved complete relief from pain. That study suggested that the effect of TFCC debridement was insufficient, with more than 1% of patients undergoing re-operation. The present findings suggest that arthroscopic TFCC debridement does t modify the natural course of recalcitrant ulnar wrist pain even in the absence of definitive signs of ulcarpal abutment seen with arthroscopy or DRUJ instability observed under anaesthesia. One study reported ulcarpal impaction syndrome in wrists with neutral or negative ulnar variance. 19 We therefore excluded patients with both TFCC disc lesions and cartilage lesions, even if ulnar variance was < 3 mm. However, TFCC debridement THE BONE & JOINT JOURNAL

9 SIMPLE DEBRIDEMENT HAS LITTLE USEFUL VALUE ON THE CLINICAL COURSE OF RECALCITRANT ULNAR WRIST PAIN 1695 USO TFCC repair p =.2 p =.1 Pain score p =.2 * * * * * * * * * p =.25 p =.43 p =.19 p =.9 * * * * * * * * * TFCC debridement Conservative treatment Pain score p =.5 p =.9 p =.29 * * * * Follow-up (mths) Follow-up (mths) Fig. 6 Bar charts showing the mean pain scores for the ulnar shortening osteotomy (USO), triangular fibrocartilage complex (TFCC) repair, TFCC debridement and conservative groups. The error bars dete the standard deviation and statistically significant p-values are given (Student s t-test). Table VII. Mean range of movement in all four groups (USO, ulnar shortening osteotomy; TFCC, triangular fibrocartilage complex) Dorsal flexion Palmar flexion Pronation Supination months 18 months p-value months 18 months p-value months 18 months p-value months 18 months p-value USO 68 (4 to 9) 76 (55 to 9).9 63 (2 to 9) 69 (4 to 9) (5 to 9) 78 (6 to 9) (25 to 9) 85 (65 to 9).7 TFCC repair 67 (5 to 8) 68 (5 to 8) (4 to 8) 63 (45 to 75) (4 to 85) 75 (6 to 9) (7 to 9) 83 (7 to 9).95 TFCC debridement 61 (23 to 9) 7 (53 to 9) (23 to 9) 7 (49 to 9) (3 to 9) 81 (7 to 9) (3 to 9) 9 (88 to 9).6 Conservative treatment 77 (5 to 9) 8 (5 to 9) (56 to 9) 81 (6 to 9) (65 to 8) 76 (7 to 9) (7 to 9) 85 (8 to 9).6 did t have any significant effect in our study. Perhaps the pathology of ulnar wrist pain may be similar to that in knee OA, and debridement may also be ineffective. 7 Wysocki et al 26 recently reported that even peripheral TFCC injury with intact deep fibres and a clinically stable DRUJ can cause recalcitrant ulnar wrist pain. They suggested that superficial fibre tear could be one reason for recalcitrant ulnar wrist pain. Superficial fibre repair may be necessary when superficial fibre tears are seen on arthroscopy. Some limitations must be considered for the present study. First, this was a retrospective study. Second, strictly speaking, we compared four groups showing different pathologies. However, within group Hand2/pain score comparisons revealed that scores in the TFCC debridement VOL. 95-B, No. 12, DECEMBER 213

10 1696 T. NISHIZUKA, M. TATEBE, H. HIRATA, T. SHINOHARA, M. YAMAMOTO, K. IWATSUKI % grip strength Follow-up (mths) Fig. 7 USO TFCC repair TFCC debridement Conservative Graph showing the mean percentage grip strength for the ulnar shortening osteotomy (USO), triangular fibrocartilage complex (TFCC) repair, TFCC debridement and conservative groups. * detes a statistically significant difference. A significant difference was identified between the USO and conservative treatment groups (p =.17), and between the TFCC repair and conservative treatment groups at 18 months post-operatively (p =.18) (Bonferroni multiple comparison test). group did t improve significantly, while those in USO and TFCC repair groups did. In addition, considering that USO and TFCC repair groups included patients with more severe pathology than the TFCC debridement group and that we excluded patients with apparent ulcarpal abutment syndrome or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement, this procedure appears worthless for surgeons treating ulnar wrist pain. In conclusion, we have provided a report of clinical outcomes for USO, arthroscopic TFCC repair and TFCC debridement, based on our treatment algorithm. Our findings indicate that TFCC debridement has little favourable impact on the clinical course of recalcitrant ulnar wrist pain, even if patients with apparent ulcarpal abutment syndrome or TFCC detachment from fovea were excluded from the indications for arthroscopic TFCC debridement. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by P. Baird and first-proof edited by G. Scott. References 1. Nakamura R. Diagsis of ulnar wrist pain. Nagoya J Med Sci 21;64: Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulcarpal impaction syndrome, and lutriquetral ligament tears. J Hand Surg Am 28;33: Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 199;6: Shihara T, Tatebe M, Okui N, et al. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 213;38: Hulsizer D, Weiss AP, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg Am 1997;22: Minami A, Ishikawa J, Suenaga N, Kasashima T. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg Am 1996;21: Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumanant C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev 28;23:CD Adams BD. Distal radioulnar joint instability. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green s operative hand surgery. Sixth ed. Philadelphia: Elsevier Churchill Livingstone, 211: Nakamura R, Hori M, Imamura T, Horii E, Miura T. Method for measurement and evaluation of carpal bone angles. J Hand Surg Am 1989;14: Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg Am 1989;14: Imaeda T, Nakamura R, Shioya K, Maki N. Ulnar impaction syndrome: MR imaging findings. Radiology 1996;21: Kim JP, Park MJ. Assessment of distal radioulnar joint instability after distal radius fracture: comparison of computed tomography and clinical examination results. J Hand Surg 28;33: Haisman JM, Matthew B, Scott W. Wrist arthroscopy: standard portals and arthroscopic anatomy. J Am Soc Surg Hand 25;5: Yamamoto M, Koh S, Tatebe M, et al. Importance of distal radioulnar joint arthroscopy for evaluating the triangular fibrocartilage complex. J Orthop Sci 21;15: Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78-A: Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. Third ed. Tokyo: Igaku- Shoin, 1978: Beguin J, Locker B. Chondropathie rotulienne: 2ème journée d'arthroscopie du geu. Vol. 1. Lyon: Lyon méd, 1983:89 9 (in French). 18. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res 1984;187: Tatebe M, Nakamura R, Horii E, Nakao E. Results of ulnar shortening osteotomy for ulcarpal impaction syndrome in wrists with neutral or negative ulnar variance. J Hand Surg Br 25;3: Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989;14: Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 211;27: Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg 28;12: Suzuki M, Kurimoto S, Shihara T, et al. Development and validation of an illustrated questionnaire to evaluate disabilities of the upper limb. J Bone Joint Surg [Br] 21;92-B: Kurimoto S, Yamamoto M, Shihara T, Tatebe M, Katsuyuki I, Hirata H. Favorable effects of explanatory illustrations attached to a self-administered questionnaire for upper extremity disorders. Qual Life Res 213;22: Siddiqui O, Ali MW. A comparison of the random-effects pattern mixture model with last-observation-carried-forward (LOCF) analysis in longitudinal clinical trials with dropouts. J Biopharm Stat 1998;8: Wysocki RW, Richard MJ, Crowe MM, Leversedge FJ, Ruch DS. Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact. J Hand Surg Am 212;37: Gaebler C, McQueen MM. Ulnar procedures for post-traumatic disorders of the distal radioulnar joint. Injury 23;34: THE BONE & JOINT JOURNAL