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Safety Analysis of All-inside Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex (SS-28)
ABSTRACTS viewed by a fellowship trained musculoskeletal radiologist blinded to clinical history other than age and gender. Arthroscopic treatment included debridement of posteromedial synovitis, loose body (if present) excision, and excision of any olecranon spur. All patients underwent a physical examination and completion of the Andrews-Carson scale with a minimum follow-up of 12 months (range: 12 - 73). Results: All patients were male with an average age of 21.2 (range: 15 - 34). The dominant arm (right ⫽ 9) was affected in all patients. The average length of symptoms prior to surgery was 9 months (range: 5 - 24). At MRI, a reproducible pattern of pathology was noted. All patients had pathology recorded at the articular surfaces of the posterior trochlea and the anterior, medial olecranon, ranging from abnormal edema like signal in the hyaline cartilage (grade 1 chondrosis) to partial thickness cartilage defects and subjacent, subchondral bone marrow edema (grade 2 or 3 chondrosis). Additional MRI findings included joint effusion, synovitis within the posteromedial recess, marginal osteophytes at the trochlea and olecranon, soft tissue edema about the distal, medial triceps insertion, ulnar collateral ligament hypertrophy, and flexor/pronator tendon origin strain. Findings at surgery included posteromedial synovitis and olecranon spurring in all patients, and loose bodies in 3 patients. Based on the Andrews-Carson scale, the subjective and objective outcome was considered excellent in 8 patients and good in 2. Conclusions: Posteromedial elbow pain as a result of impingement has a reproducible pattern of pathology on MRI in throwing athletes. Arthroscopic debridement, olecranon spur excision, and loose body excision if present allows return to throwing sports, and excellent subjective and objective results. Wrist Arthroscopy: Evaluating the Effectiveness of Clinical Tests and the Standard MRI in the Detection of Tears of the Triangular Fibrocartilage Complex of the Wrist (SS-27) Victor Vaquerizo-Garcia, Resident, Ramon Perez, Orthopedic Surgeon, Elias Zarka, Orthopedic Surgeon, Jose Antonio Pareja, Orthopedic Surgeon, Fernando Viloria-Recio, Resident, Eulogio Benito, Orthopedic Surgeon, Esther Montes, Nurse, and Alberto Gomez, Resident Introduction: At present controversy exists in the diagnostic value of MRI for carpal ligaments injuries and triangular fibrocartilage complex (TFCC), although in case of triangular fibrocartilage complex injuries surgical treatment differs depending on type of tears, central or peripheral. The preoperative diagnosis is essential for
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appropriate treatment. The aim of our study is to determine the sensitivity, specificity, positive predictive value and negative predictive value of clinical trials and standard MRI wrist in the detection of tears of the triangular fibrocartilage complex. Methods: Thirty patients with chronic wrist pain were operated by wrist arthroscopy between 1999 and 2006. We evaluated sex, age, the presence of clinical signs of triangular fibrocartilage complex injury, and were compared with results of the MRI and arthroscopic findings. It was felt arthroscopy accepted as the gold standard. Results: There were females (73%), the mean age was 33.3 years, clinical signs of triangular fibrocartilage complex injury were in 80% of patients, and MRI reported synovitis in 40% and of triangular fibrocartilage complex rupture or tears in 60% of cases. During the arthroscopy in 57% of cases was found synovitis and 43% tears of the triangular fibrocartilage complex. The sensitivity of MRI is 58.3%, specificity is 43.75%. The sensitivity of clinical examination is 91.6% while the specificity was 26.6%. There were no statistically significant differences between physical examination and MRI. Conclusions: Formerly the diagnosis in patients with chronic pain wrist was performed by direct visualization or arthrography. MRI represents a non-invasive test with high sensitivity but its results depend on the experience of the radiologist, location of the lesion and size of the lesion. The use of arthroMRI together with high resolution has improved sensitivity but still technical improvements to compare with arthroscopy in diagnostic of tears of the triangular fibrocartilage complex.
Safety Analysis of All-inside Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex (SS28) Scott M. Waterman, MD, Dirk Slade, MD, Brendan Masini, MD, and Brett Owens, MD Summary: This study evaluates the safety of an allinside peripheral triangular fibrocartilage complex repair by determining the proximity of the anchors to ulnarsided anatomical structures. Secondary to the close proximity of both the dorsal ulnar sensory nerve and extensor carpi ulnaris tendon, caution should be used with this repair technique. Introduction: The purpose of this study is to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasTfix(tm) device is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures.
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ABSTRACTS
Methods: Twelve fresh frozen cadaver wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all -inside arthroscopic peripheral TFCC repair was completed by placing a single FasTfix(tm) device in a vertical mattress fashion. The wrists were then dissected to visualize the two anchors. The distance between these anchors and the flexor carpi ulnaris, extensor carpi ulnaris, and dorsal sensory nerve were measured with digital calipers and recorded. Results: The peripheral anchor averaged 4.2 mm (0-14 mm) from the extensor carpi ulnaris tendon, 3.8 mm (0-9 mm) from the dorsal ulnar sensory nerve, and 8.3 mm (1-15 mm) from the flexor carpi ulnaris tendon. The central anchor averaged 9.6 mm (2-15 mm) from the extensor carpi ulnaris tendon, 6.8 mm (1-13 mm) from the dorsal ulnar sensory nerve, and 7.6 mm (1-13 mm) from the flexor carpi ulnaris tendon. Conclusions: This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasTfix(tm) device, which was found to reside in close proximity to the extensor carpi ulnaris, flexor carpi ulnaris, and dorsal ulnar sensory nerve. In multiple wrists, the anchors were noted to underlie the anatomical structure that we measured making it possible to pierce these structures with the needle prior to deployment of the anchor. Caution should be used with this repair technique. Prevalence of CAM Type FAI Morphology in 200 Asymptomatic Volunteers (SS-29) Paul Beaule, MD, FRCSC, Kalesha Hack, MD, Kawan Rakhra, MD, FRCPC, and Gina DiPrimio, MD, FRCPC Introduction: Osteoarthritis of the hip is a debilitating and painful condition affecting a significant proportion of the population. A growing body of literature confirms that idiopathic OA is frequently caused by subtle, and often radiographically occult, abnormalities at the femoral head-neck junction or acetabulum that result in abnormal contact between the femur and acetabulum. This condition, known as femoroacetabular impingement, is a widely accepted cause of early OA of the hip. MRI is the imaging modality that is most sensitive in detecting CAM morphology. The association between patients presenting with hip pain, signs of impingement on physical exam and abnormalities of the femoral headneck junction is clearly outlined in the literature. However, there is currently little published data regarding the prevalence of abnormalities of the femoral head-neck junction in patients without hip pain or previous hip pathology. There is currently no published prospective study which examines the prevalence of CAM morphol-
ogy in asymptomatic individuals using currently accepted methods for quantifying femoral head-neck morphology as described by Notzli et al. This information is needed to better understand the natural course of this disease. The primary aim of this project is to examine the incidence of CAM morphology in a population without hip pain or pre-existing hip disease using non-contrast MRI. We hypothesize that the prevalence of CAM morphology will approach 20% in asymptomatic patients. Methods: 200 asymptomatic volunteers underwent magnetic resonance imaging targeted to both hips. Subjects were examined at the time of MRI to document internal rotation of the hips at 90 degrees flexion and to assess for a positive impingement sign. The mean age was 29 years (range 21-46); 76% were Caucasian and 53% female. The Nötzli alpha angle was measured on oblique axial images through the middle of the femoral neck for each hip. A value greater than 50 degrees was considered consistent with cam morphology. Measurements were performed independently by 2 musculoskeletal radiologists. Results: 28% of volunteers had at least one hip with cam morphology: 18% had an elevated alpha angle on either the right or the left side, and 10% had bilateral deformity. The average alpha angle was 42.7 degrees on the right (SD⫽7.5) and 42.8 degrees on the left (SD⫽8.2). Internal rotation was negatively correlated with alpha angle (p⬍.05). Patients with an elevated alpha angle on at least one side tended to be male (p⬍.01). Conclusions: The high prevalence of cam morphology in asymptomatic individuals is critical information in determining the natural history of FAI as well as establishing treatment strategies in patients presenting with pre-arthritic hip pain. Prevalence of Associated Deformities in Patients with Cam Type Femoroacetabular Impingement (SS-30) Paul Beaule, MD, FRCSC, David Allen, MD, FRCS Ed (Orth), Steve Doucette, MSc, and Othman Ramadan, MD Introduction: Femoroacetabular impingement (FAI) has recently been described as a cause of hip pain in young adults and a cause of osteoarthritis of the hip. Cam type impingement is due to a non-constant radius of curvature of the femoral head, usually due to a prominence at the anterosuperior head-neck junction. The surgical treatment of FAI may be able to prevent or retard the progression of degeneration within the hip. One critical aspect in the understanding of the natural history of any hip condition is determining the prevalence of bilateral disease. This clinical information can also be very useful for patient counseling, development of treat-
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appropriate treatment. The aim of our study is to determine the sensitivity, specificity, positive predictive value and negative predictive value of clinical trials and standard MRI wrist in the detection of tears of the triangular fibrocartilage complex. Methods: Thirty patients with chronic wrist pain were operated by wrist arthroscopy between 1999 and 2006. We evaluated sex, age, the presence of clinical signs of triangular fibrocartilage complex injury, and were compared with results of the MRI and arthroscopic findings. It was felt arthroscopy accepted as the gold standard. Results: There were females (73%), the mean age was 33.3 years, clinical signs of triangular fibrocartilage complex injury were in 80% of patients, and MRI reported synovitis in 40% and of triangular fibrocartilage complex rupture or tears in 60% of cases. During the arthroscopy in 57% of cases was found synovitis and 43% tears of the triangular fibrocartilage complex. The sensitivity of MRI is 58.3%, specificity is 43.75%. The sensitivity of clinical examination is 91.6% while the specificity was 26.6%. There were no statistically significant differences between physical examination and MRI. Conclusions: Formerly the diagnosis in patients with chronic pain wrist was performed by direct visualization or arthrography. MRI represents a non-invasive test with high sensitivity but its results depend on the experience of the radiologist, location of the lesion and size of the lesion. The use of arthroMRI together with high resolution has improved sensitivity but still technical improvements to compare with arthroscopy in diagnostic of tears of the triangular fibrocartilage complex.
Safety Analysis of All-inside Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex (SS28) Scott M. Waterman, MD, Dirk Slade, MD, Brendan Masini, MD, and Brett Owens, MD Summary: This study evaluates the safety of an allinside peripheral triangular fibrocartilage complex repair by determining the proximity of the anchors to ulnarsided anatomical structures. Secondary to the close proximity of both the dorsal ulnar sensory nerve and extensor carpi ulnaris tendon, caution should be used with this repair technique. Introduction: The purpose of this study is to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasTfix(tm) device is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures.
e16
ABSTRACTS
Methods: Twelve fresh frozen cadaver wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all -inside arthroscopic peripheral TFCC repair was completed by placing a single FasTfix(tm) device in a vertical mattress fashion. The wrists were then dissected to visualize the two anchors. The distance between these anchors and the flexor carpi ulnaris, extensor carpi ulnaris, and dorsal sensory nerve were measured with digital calipers and recorded. Results: The peripheral anchor averaged 4.2 mm (0-14 mm) from the extensor carpi ulnaris tendon, 3.8 mm (0-9 mm) from the dorsal ulnar sensory nerve, and 8.3 mm (1-15 mm) from the flexor carpi ulnaris tendon. The central anchor averaged 9.6 mm (2-15 mm) from the extensor carpi ulnaris tendon, 6.8 mm (1-13 mm) from the dorsal ulnar sensory nerve, and 7.6 mm (1-13 mm) from the flexor carpi ulnaris tendon. Conclusions: This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasTfix(tm) device, which was found to reside in close proximity to the extensor carpi ulnaris, flexor carpi ulnaris, and dorsal ulnar sensory nerve. In multiple wrists, the anchors were noted to underlie the anatomical structure that we measured making it possible to pierce these structures with the needle prior to deployment of the anchor. Caution should be used with this repair technique. Prevalence of CAM Type FAI Morphology in 200 Asymptomatic Volunteers (SS-29) Paul Beaule, MD, FRCSC, Kalesha Hack, MD, Kawan Rakhra, MD, FRCPC, and Gina DiPrimio, MD, FRCPC Introduction: Osteoarthritis of the hip is a debilitating and painful condition affecting a significant proportion of the population. A growing body of literature confirms that idiopathic OA is frequently caused by subtle, and often radiographically occult, abnormalities at the femoral head-neck junction or acetabulum that result in abnormal contact between the femur and acetabulum. This condition, known as femoroacetabular impingement, is a widely accepted cause of early OA of the hip. MRI is the imaging modality that is most sensitive in detecting CAM morphology. The association between patients presenting with hip pain, signs of impingement on physical exam and abnormalities of the femoral headneck junction is clearly outlined in the literature. However, there is currently little published data regarding the prevalence of abnormalities of the femoral head-neck junction in patients without hip pain or previous hip pathology. There is currently no published prospective study which examines the prevalence of CAM morphol-
ogy in asymptomatic individuals using currently accepted methods for quantifying femoral head-neck morphology as described by Notzli et al. This information is needed to better understand the natural course of this disease. The primary aim of this project is to examine the incidence of CAM morphology in a population without hip pain or pre-existing hip disease using non-contrast MRI. We hypothesize that the prevalence of CAM morphology will approach 20% in asymptomatic patients. Methods: 200 asymptomatic volunteers underwent magnetic resonance imaging targeted to both hips. Subjects were examined at the time of MRI to document internal rotation of the hips at 90 degrees flexion and to assess for a positive impingement sign. The mean age was 29 years (range 21-46); 76% were Caucasian and 53% female. The Nötzli alpha angle was measured on oblique axial images through the middle of the femoral neck for each hip. A value greater than 50 degrees was considered consistent with cam morphology. Measurements were performed independently by 2 musculoskeletal radiologists. Results: 28% of volunteers had at least one hip with cam morphology: 18% had an elevated alpha angle on either the right or the left side, and 10% had bilateral deformity. The average alpha angle was 42.7 degrees on the right (SD⫽7.5) and 42.8 degrees on the left (SD⫽8.2). Internal rotation was negatively correlated with alpha angle (p⬍.05). Patients with an elevated alpha angle on at least one side tended to be male (p⬍.01). Conclusions: The high prevalence of cam morphology in asymptomatic individuals is critical information in determining the natural history of FAI as well as establishing treatment strategies in patients presenting with pre-arthritic hip pain. Prevalence of Associated Deformities in Patients with Cam Type Femoroacetabular Impingement (SS-30) Paul Beaule, MD, FRCSC, David Allen, MD, FRCS Ed (Orth), Steve Doucette, MSc, and Othman Ramadan, MD Introduction: Femoroacetabular impingement (FAI) has recently been described as a cause of hip pain in young adults and a cause of osteoarthritis of the hip. Cam type impingement is due to a non-constant radius of curvature of the femoral head, usually due to a prominence at the anterosuperior head-neck junction. The surgical treatment of FAI may be able to prevent or retard the progression of degeneration within the hip. One critical aspect in the understanding of the natural history of any hip condition is determining the prevalence of bilateral disease. This clinical information can also be very useful for patient counseling, development of treat-