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Arthroscopic Diagnosis of the Triangular Fibrocartilage Complex Foveal Tear: A Cadaver Assessment

Published:February 03, 2018DOI:https://doi.org/10.1016/j.jhsa.2017.12.017

      Purpose

      To determine whether the arthroscopic hook and trampoline tests are accurate and reliable diagnostic tests for foveal triangular fibrocartilage complex (TFCC) detachment.

      Methods

      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.

      Results

      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 3 observers. 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.

      Conclusions

      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.

      Clinical relevance

      The hook test is a sensitive, specific, and reliable test for the diagnosis of isolated TFCC foveal detachment.

      Key words

      The triangular fibrocartilage complex (TFCC) consists of the articular disc, meniscus homolog, dorsal and volar radioulnar ligaments, ulnocarpal ligaments, ulnar joint capsule, and extensor carpi ulnaris subsheath.
      • Palmer A.K.
      Triangular fibrocartilage complex lesions: A classification.
      The TFCC serves as a cushion between the ulna and the ulnar carpus as well as a stabilizer of the ulnocarpal and distal radioulnar (DRUJ) joints. Normal TFCC anatomy facilitates smooth forearm and wrist motion. TFCC tears may result in ulnar-sided wrist pain, DRUJ instability, and functional impairment. The Palmer classification categorizes TFCC tears based on anatomical location.
      • Palmer A.K.
      Triangular fibrocartilage complex lesions: A classification.
      Palmer 1-B tears refer to traumatic, peripheral, ulnar-sided tears and have been further subdivided based on TFCC detachment distally (ie, from the ulnar styloid insertion) versus proximally (ie, from the foveal insertion) (Table 1).
      • Nakamura T.
      • Yabe Y.
      • Horiuchi Y.
      Functional anatomy of the triangular fibrocartilage complex.
      • Atzei A.
      • Luchetti R.
      • Braidotti F.
      Arthroscopic foveal repair of the triangular fibrocartilage complex.
      The foveal insertion, where the deep fibers of the distal radioulnar ligaments insert, is an important contributor to DRUJ stability.
      • Nakamura T.
      • Takayama S.
      • Horiuchi Y.
      • Yabe Y.
      Origins and insertions of the triangular fibrocartilage complex: a histological study.
      • Ishii S.
      • Palmer A.K.
      • Werner F.W.
      • Short W.H.
      • Fortino M.D.
      An anatomic study of the ligamentous structure of the triangular fibrocartilage complex.
      • Shin W.J.
      • Kim J.P.
      • Yang H.M.
      • Lee E.Y.
      • Go J.H.
      • Heo K.
      Topographical anatomy of the distal ulna attachment of the radioulnar ligament.
      Table 1Palmer 1-B TFCC Tears: Arthroscopic Findings Based on Tear Location
      Distal TearIsolated Proximal Tear
      TFCC anatomyDisrupted ulnar styloid insertionDisrupted foveal insertion
      Radiocarpal joint arthroscopyPeripheral tear visibleNo tear visible
      Trampoline testPositive
      Hook testPositive
      Arthroscopic tests have been described for the diagnosis of TFCC tears. The trampoline test assesses TFCC tension by applying a compressive load with a probe and then visualizing TFCC compliance. Distal, but not isolated proximal, Palmer 1-B tears are associated with a positive trampoline test (Table 1).
      • Atzei A.
      • Luchetti R.
      • Braidotti F.
      Arthroscopic foveal repair of the triangular fibrocartilage complex.
      • Hermansdorfer J.D.
      • Kleinman W.B.
      Management of chronic peripheral tears of the triangular fibrocartilage complex.
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      Isolated foveal TFCC tears may not be apparent during radiocarpal joint arthroscopy because these tears are located on the undersurface of the TFCC. The hook test has been described to assess the foveal insertion of the TFCC by placing a probe from the 6R or 4-5 portal into the prestyloid recess and then applying a radially directed traction force to the TFCC periphery (Table 1).
      • Ruch D.S.
      • Yang C.C.
      • Smith B.P.
      Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures.
      A positive hook test occurs when the TFCC can be displaced off of the ulna head (ie, distally and radially) by the probe.
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      • Ruch D.S.
      • Yang C.C.
      • Smith B.P.
      Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures.
      • Atzei A.
      • Rizzo A.
      • Luchetti R.
      • Fairplay T.
      Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability.
      The TFCC repair techniques in which the TFCC periphery is sutured to the capsule and/or the extensor carpi ulnaris subsheath, do not retension the foveal insertion. Thus, it is not surprising that DRUJ instability is a leading cause of failure and reoperation after traditional arthroscopic TFCC-to-capsule repair.
      • Anderson M.L.
      • Larson A.N.
      • Moran S.L.
      • Cooney W.P.
      • Amrami K.K.
      • Berger R.A.
      Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears.
      • Estrella E.P.
      • Hung L.K.
      • Ho P.C.
      • Tse W.L.
      Arthroscopic repair of triangular fibrocartilage complex tears.
      Specialized techniques to repair the TFCC foveal insertion via foveal suture anchor placement or transosseous suture repair via an ulnar tunnel have been described.
      • Atzei A.
      • Luchetti R.
      • Braidotti F.
      Arthroscopic foveal repair of the triangular fibrocartilage complex.
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      • Atzei A.
      • Rizzo A.
      • Luchetti R.
      • Fairplay T.
      Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability.
      • Kim B.
      • Yoon H.K.
      • Nho J.H.
      • et al.
      Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient.
      • Nakamura T.
      • Sato K.
      • Okazaki M.
      • Toyama Y.
      • Ikegami H.
      Repair of foveal detachment of the triangular fibrocartilage complex: Open and arthroscopic transosseous techniques.
      • Iwasaki N.
      • Minami A.
      Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head.
      However, despite clinical recognition of the importance of the TFCC foveal tear, diagnosis remains a challenge because these tears may not be apparent during routine radiocarpal joint arthroscopy.
      The aim of this study was to assess the accuracy and diagnostic reliability of the arthroscopic hook and trampoline tests in the setting of isolated foveal TFCC detachment.

      Materials and Methods

      Seventeen cadaveric extremities were used for this investigation. Two of these cadavers were used to standardized the study protocol, providing 15 unpaired upper extremities amputated at the mid-humerus level for study. Age, sex, and laterality of cadaveric specimens were recorded. Ulnar variance was measured on calibrated posteroanterior wrist radiographs in neutral forearm rotation using perpendicular lines.
      • Mann F.A.
      • Wilson A.J.
      • Gilula L.A.
      Radiographic evaluation of the wrist: what does the hand surgeon want to know?.
      Wrist arthroscopy was performed with a 2.7-mm arthroscope with saline irrigation and the cadaver extremity in a traction setup. Diagnostic radiocarpal joint arthroscopy was performed to document any preexisting intercarpal and/or TFCC anomalies using 3-4 and 6R portals. There were 5 preexisting TFCC tears, which were excluded from all analyses: 1 large complex degenerative tear, 1 isolated foveal tear, and 3 peripheral tears. Thus, the remaining 10 specimens were analyzed.
      Arthroscopic hook and trampoline tests were performed and arthroscopic videos recorded (baseline). The arthroscopic hook test was performed as described by Ruch et al.
      • Ruch D.S.
      • Yang C.C.
      • Smith B.P.
      Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures.
      A radially directed traction force was applied to the TFCC periphery by a probe inserted from the 6R portal into the prestyloid recess. A positive hook test occurred when the TFCC was displaced off the ulna head (ie, distally and radially) by the probe. The arthroscopic trampoline test was performed as described by Hermansdorfer and Kleinman.
      • Hermansdorfer J.D.
      • Kleinman W.B.
      Management of chronic peripheral tears of the triangular fibrocartilage complex.
      A compressive load was applied to the TFCC by a probe inserted into the 6R portal. A positive trampoline test occurred when the TFCC was soft and compliant as opposed to taut.
      The deep foveal attachment of the TFCC was then detached with a beaver blade through a small ulnar incision (foveal detachment). The blade was swept from volar to dorsal and from ulnar to radial while remaining directly on the distal ulna. This maneuver created a linear horizontal defect detaching the foveal insertion, while maintaining the distal ulnar styloid insertion. Deep beaver blade placement (ie, undersurface of the TFCC) was confirmed indirectly by radiocarpal arthroscopy. This step was performed by the senior author (C.A.G.) in all specimens. Foveal detachment replicated a type 2 tear as described by Moritomo et al
      • Moritomo H.
      • Arimitsu S.
      • Kubo N.
      • Masatomi T.
      • Yukioka M.
      Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears.
      and class 3 TFCC tear as described by Atzei and Luchetti
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      (Table 2). The hook and trampoline tests were then repeated and videos recorded. Finally, the foveal detachment was repaired via an ulnar tunnel technique (repair).
      • Nakamura T.
      • Sato K.
      • Okazaki M.
      • Toyama Y.
      • Ikegami H.
      Repair of foveal detachment of the triangular fibrocartilage complex: Open and arthroscopic transosseous techniques.
      The hook test was repeated and video recorded. Because suture material was visible on postrepair videos, these videos were not included in sensitivity, specificity, or reliability analyses. In total, 5 arthroscopic videos were recorded for each of the 10 specimens (ie, 50 videos).
      Table 2TFCC Foveal Tear Classification
      Atzei and Luchetti
      • Hermansdorfer J.D.
      • Kleinman W.B.
      Management of chronic peripheral tears of the triangular fibrocartilage complex.
      Class 0Class 1Class 2Class 3Class 4Class 5
      DescriptionIsolated ulnar styloid fracture; no TFCC tearDistal TFCC tear (ulnar styloid insertion)Complete TFCC tearProximal TFCC tear (foveal insertion)Non-repairable TFCC tearDistal radioulnar joint arthritis
      Arthroscopic FindingsNo tear on radiocarpal arthroscopy; negative hook testPeripheral tear; negative hook testNo tear on radiocarpal arthroscopy; positive hook testNo tear on radiocarpal arthroscopy; positive hook testMassive tear with degenerated edgesVariable tear pattern with cartilage defect
      Moritomo et al
      • Moritomo H.
      • Arimitsu S.
      • Kubo N.
      • Masatomi T.
      • Yukioka M.
      Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears.
      Class 1Class 2Class 3Class 4Class 5
      DescriptionNormal. TFCC arises from radius and inserts at fovea and ulnar styloid baseLinear, horizontal defect at foveal insertion with intact ulnar styloid insertionRound ulnar-sided defect of the deep fibers of the radioulnar ligaments at the foveal insertion; ulnar styloid insertion intactLarge ulnar-sided defect affecting both foveal and ulnar styloid insertionsSlitlike defect of the proximal and ulnar TFCC
      Following completion of the cadaveric protocol, posttesting dissection was performed to confirm complete foveal detachment of the TFCC. In all specimens, isolated foveal TFCC tears had been successfully created and fibers of the distal radioulnar ligaments remained intact dorsally and volarly. It should be noted that the cadaveric protocol, including video recording, was standardized prior to study initiation so that 3 investigators (S.K.T., L.B.W., and C.A.G.) performed all steps in identical fashion (except TFCC foveal detachment, which was performed only by the senior author [C.A.G.]).
      The videos were then reviewed by three independent observers—2 fellowship-trained hand surgeons (R.P.C. and C.J.D.) and 1 hand surgery fellow (S.M.Y.)—who had not participated in the arthroscopies or video preparation. The 3 observers independently reviewed the videos in a randomized, blinded fashion and categorized the trampoline and hook tests as positive or negative. Prior to video review, observers were shown 4 example videos—positive and negative hook and trampoline tests—taken during arthroscopy of pilot specimens not included in the study. The negative and positive hook test videos are Videos A and B, respectively (available on the Journal’s Web site at www.jhandsurg.org). Observers could view each video multiple times, as needed, but were unable to revisit a previously reviewed video. At least 2 weeks after initial video review, the videos were rereviewed in a randomized, blinded fashion.
      Comparisons of proportions of categorical variables were performed via 2-tailed Fisher exact test. Inter- and intraobserver reliabilities were assessed via Cohen kappa coefficient. Cohen kappa accounts for the possibility of chance agreement. The number of cadaveric specimens was a sample of convenience.

      Results

      The mean age at death of the cadaveric specimens was 41 years (range, 26–57 years). There were 5 male and 5 female extremities. There were 6 right and 4 left unpaired upper extremities.
      Randomized blinded review of the 10 baseline and 10 foveal detachment hook test videos by the 3 observers demonstrated that 10% (3 of 30) and 90% (27 of 30) were graded as positive, respectively (P < .05); and hook test sensitivity and specificity for isolated foveal detachment diagnosis were 90% and 90%, respectively. There was 90% (18/20) agreement among all 3 observers for the baseline and foveal detachment hook test videos. Hook test interobserver reliability Cohen kappa was 0.87. The intraobserver reliability Cohen kappa averaged 0.81 among the 3 observers (0.71, 0.81, and 0.90). Finally, following ulnar tunnel repair, 20% (6 of 30) of hook tests were graded as positive in comparison with 90% positive with foveal detachment (P < .05) and 10% positive at baseline.
      Randomized blinded video review demonstrated that 17% (5 of 30) of trampoline tests were graded as positive at baseline and 43% (13 of 30) were graded as positive after isolated foveal detachment (P < .05). There was 45% (9 of 20) agreement among all 3 observers for the baseline and foveal detachment trampoline test videos. Trampoline test interobserver reliability Cohen kappa was 0.16. The intraobserver reliability Cohen kappa averaged 0.63 among the three observers (0.57, 0.62, and 0.69). Sensitivity and specificity of the trampoline test in diagnosing foveal detachment were 43% and 83%, respectively.

      Discussion

      In this cadaveric study, 3 blinded observers interpreted the video recordings of the arthroscopic hook and trampoline tests at baseline and following isolated TFCC foveal detachment. The hook test was sensitive (90%), specific (90%), and reliable (Cohen kappa 0.87 and 0.81 for inter- and intraobserver, respectively). As expected, the trampoline test had lower sensitivity (43%), specificity (83%), and reliability (Cohen kappa 0.16 and 0.63 for inter- and intraobserver, respectively). Finally, the proportion of positive hook tests decreased following TFCC foveal repair using an ulnar tunnel technique from 90% (foveal detachment) to 20% (vs 10% in the intact baseline state).
      The inter- and intraobserver reliabilities of photographs and videos recorded during diagnostic wrist arthroscopy have been previously studied.
      • Low S.
      • Prommersberger K.J.
      • Pillukat T.
      • van Schoonhoven J.
      Intra- and interobserver reliability of digitally photodocumented findings in wrist arthroscopy.
      • Low S.
      • Pillukat T.
      • Prommersberger K.J.
      • van Schoonhoven J.
      The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability.
      • Low S.
      • Erne H.
      • Schutz A.
      • Eingartner C.
      • Spies C.K.
      The required minimum length of video sequences for obtaining a reliable interobserver diagnosis in wrist arthroscopies.
      Blinded review of arthroscopic photographs and videos during 60 wrist arthroscopies by 2 independent observers demonstrated interobserver reliabilities for the assessment of a cartilage lesion, trampoline test, TFCC tear, scapholunate ligament tear, and lunotriquetral ligament tear with Cohen kappa coefficients of 0.51, 0.40, 0.41, 0.32, and 0.21, respectively.
      • Low S.
      • Pillukat T.
      • Prommersberger K.J.
      • van Schoonhoven J.
      The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability.
      A subsequent study by Low et al
      • Low S.
      • Erne H.
      • Schutz A.
      • Eingartner C.
      • Spies C.K.
      The required minimum length of video sequences for obtaining a reliable interobserver diagnosis in wrist arthroscopies.
      in which longer videos were analyzed arrived at a similar conclusion regarding the interobserver reliability of the trampoline test (Cohen kappa 0.32–0.46). Although our interobserver reliability for the trampoline test (Cohen kappa 0.16) is lower than previously reported, this value becomes consistent with previous studies if we include the 5 excluded specimens with preexisting tears (Cohen kappa 0.30). The interobserver reliabilities reported by us and others raise potential concerns regarding the reliability of the trampoline test. Of note, we did not study distal Palmer 1-B tears, which affect the ulnar styloid insertion of the TFCC, and have been associated with a positive trampoline test.
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      Although previous authors have described the arthroscopic hook test technique and its utility in foveal tear diagnosis, its accuracy and reliability have not been studied.
      • Ruch D.S.
      • Yang C.C.
      • Smith B.P.
      Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures.
      Given that isolated foveal TFCC tears (Atzei and Luchetti class 3) may not be visible during radiocarpal arthroscopy and traditional TFCC repairs (in which the TFCC periphery is sutured to the capsule and/or extensor carpi ulnaris subsheath) do not retension the foveal insertion, accurate diagnosis and treatment of foveal TFCC tears is critical to optimize clinical outcome. This study provides evidence that the hook test is sensitive, specific, and reliable in the assessment of the foveal insertion of the TFCC.
      Several limitations were inherent to our cadaveric model. First, simulated TFCC foveal detachment in the cadaveric specimens may not accurately reflect all clinical injury patterns with associated soft tissue injury. Arthroscopically assisted foveal release was performed by the senior author (C.A.G.) to re-create a type 2 tear as described by Moritomo et al
      • Moritomo H.
      • Arimitsu S.
      • Kubo N.
      • Masatomi T.
      • Yukioka M.
      Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears.
      and class 3 TFCC tear as described by Atzei and Luchetti
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      (ie, release of the proximal foveal TFCC insertion, while keeping the distal ulnar styloid insertion intact). This injury pattern was chosen given our belief that isolated, undersurface, foveal TFCC tears are underdiagnosed owing to the often normal appearance of the distal surface of the TFCC during routine radiocarpal arthroscopy. Our data demonstrate that the hook test is accurate and reliable for diagnosing this injury pattern. However, further study is required to determine the sensitivity and specificity of the hook test in other clinically relevant injury patterns. Second, DRUJ arthroscopy with a 1.9-mm arthroscope has been described to directly visualize the undersurface of the TFCC and diagnose foveal tears.
      • Slutsky D.J.
      Arthroscopic evaluation of the foveal attachment of the triangular fibrocartilage.
      Distal radioulnar joint arthroscopy was not performed in this study; however, given our data, we believe DRUJ arthroscopy is not required to diagnose a foveal TFCC tear. Third, video recording length was not controlled in this study. A previous study has demonstrated that wrist arthroscopic video length affects the reliability of blinded observer interpretation and recommended that diagnostic radiocarpal joint arthroscopy video recordings last 60 seconds.
      • Low S.
      • Erne H.
      • Schutz A.
      • Eingartner C.
      • Spies C.K.
      The required minimum length of video sequences for obtaining a reliable interobserver diagnosis in wrist arthroscopies.
      Fourth, although the use of video recordings of the hook and trampoline tests facilitated randomized blinded review by multiple observers, these video recordings could not provide the tactile feedback that some surgeons may consider to be a critical component of these arthroscopic tests. Fifth, saline irrigation during wrist arthroscopy may potentially alter TFCC tension owing to joint fluid distension and, thus, affect the outcomes of the hook and trampoline tests. Finally, although the proportion of positive hook tests significantly decreased following TFCC foveal repair (from 90% to 20%), 20% of hook tests still remained positive following repair (compared with 10% at baseline). It is possible that the ulnar tunnel repair technique was inadequate in a subset of specimens. It is also possible that a difference existed between the repair and the baseline conditions, but our study was not powered to detect this difference.
      Previous studies have validated diagnostic and/or classification criteria via multiple observer review of arthroscopic videos in both cadaveric specimens and live patients.
      • Cameron M.L.
      • Briggs K.K.
      • Steadman J.R.
      Reproducibility and reliability of the outerbridge classification for grading chondral lesions of the knee arthroscopically.
      • Marx R.G.
      • Connor J.
      • Lyman S.
      • et al.
      Multirater agreement of arthroscopic grading of knee articular cartilage.
      • Nepple J.J.
      • Larson C.M.
      • Smith M.V.
      • et al.
      The reliability of arthroscopic classification of acetabular rim labrochondral disease.
      Our data support the use of the hook test, but not the trampoline test, for foveal TFCC tear diagnosis. Our data also raise concerns regarding the reliability of the trampoline test. Furthermore, foveal TFCC tear repair via an ulnar tunnel technique led to near-normalization of the hook test to baseline. Thus, the hook test may serve as both a diagnostic tool, as well as metric of repair success. Taken together, future research should focus on the generalizability of these findings in patients treated for foveal TFCC tears.

      Acknowledgments

      Arthrex, Inc., provided cadaver specimens, laboratory space, and materials for TFCC repair.
      C.J.D. received a Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448, Subaward KL2 TR000450 (C.J.D.) from the National Institutes of Health (NIH)—National Center for Advancing Translational Sciences (NCATS), components of the NIH, and NIH Roadmap for Medical Research.

      Supplementary Data

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