The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 9

Scientific Articles | May 02, 2012

Diagnostic Accuracy of Magnetic Resonance Imaging and Magnetic Resonance Arthrography for Triangular Fibrocartilaginous Complex Injury: A Systematic Review and Meta-Analysis

Toby O. Smith, BSc(Hons), MSc, MCSP¹; Benjamin Drew, BSc(Hons), MCSP²; Andoni P. Toms, FRCS, FRCR³; Christina Jerosch-Herold, DipCOT, MSc, PhD¹; Adrian J. Chojnowski, MB BChir, FRCS(Tr&Orth)³

¹ Queen’s Building, School of Allied Health Professions, University of East Anglia, Norwich NR4 7TJ, United Kingdom. E-mail address for T.O. Smith: toby.smith@uea.ac.uk
² West Suffolk Hospital, Hardwick Lane, Bury St. Edmunds, Suffolk IP33 2QZ, United Kingdom
³ Norfolk and Norwich Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, United Kingdom

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Investigation performed at the Faculty of Health, University of East Anglia, Norwich, United Kingdom

J Bone Joint Surg Am, 2012 May 02;94(9):824-832. doi: 10.2106/JBJS.J.01775

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Abstract

Background:

Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulnar-sided wrist pain and resultant functional disability. Diagnosis is based on the history and clinical examination as well as radiographic evidence of a TFCC central perforation or a radial/ulnar tear. The purpose of this study was therefore to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in the detection of TFCC injury in the adult population.

Methods:

Published and unpublished literature databases were searched. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary receiver operating characteristic curve evaluations were performed. The methodological quality of each study was assessed with use of the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool.

Results:

Twenty-one studies were included in the review, and these series included a total of 982 wrists. On meta-analysis, MRA was superior to MRI in the investigation of full-thickness TFCC tears, with a pooled sensitivity of 0.75 and a pooled specificity of 0.81 for MRI compared with 0.84 and 0.95, respectively, for MRA. MRA and MRI performed at greater field strengths were reported to have greater sensitivity and specificity than those performed at lower field strengths. There were insufficient data to assess the diagnostic test accuracy for partial-thickness TFCC tears.

Conclusions:

Given its acceptable diagnostic test accuracy, it is recommended that MRA, rather than MRI, be performed in when there are questions about the diagnosis and subsequent management of patients with ulnar-sided wrist pain.

Level of Evidence:

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Triangular fibrocartilaginous complex (TFCC) injuries are common sources of ulnar-sided wrist pain with resultant functional disability, and they may lead to instability of the distal radioulnar joint^1-6. The TFCC is composed of the central fibrocartilage, meniscal homologue, dorsal and palmar distal radioulnar ligaments, ulnolunate ligament, ulnotriquetral ligament, and subsheath of the extensor carpi ulnaris tendon^1,2,7-9. The role of the TFCC is to distribute stresses from the carpus to the forearm; to provide stability for the distal radioulnar joint, particularly when the distal radioulnar ligaments become taut; and to provide stability during pronation and supination^2,10,11. TFCC injury has been attributed to either degenerative changes or trauma. Up to 40% of distal radial fractures have been reported to have an associated TFCC injury^9,12,13.

Diagnosis of a TFCC perforation is considered a complex and difficult clinical issue^14,15. The physical examination and history do not always lead to a clear diagnosis¹⁴. Radiography is therefore utilized to enhance the accuracy of the diagnosis^14,16. This has typically been in the form of radiographic arthrography^17,18. It is imperative that the orthopaedic clinician make a correct diagnosis because the success of the subsequent intervention, such as cast immobilization, arthroscopic debridement, direct surgical repair, dorsal capsulodesis techniques, or partial intercarpal arthrodesis, may be solely determined by the ability to define the pathology^17,19-21.

Magnetic resonance imaging (MRI) is a noninvasive technique used to evaluate intra-articular radiocarpal derangement^5,10. Because of its noninvasive nature, ability to detect soft-tissue contrasts and resolution, and multiplanar capabilities, authors have suggested a preference for MRI over radiographic arthrography^16,22,23. However, early findings of MRI assessments were considered less accurate and more difficult to interpret, with limited spatial resolution, than radiocarpal arthrography for the detection of full-thickness TFCC tears¹⁸. Through technical advances, the development of 3.0-T MR machines and specialist surface coils, and improvements in signal-to-noise ratio, the resolution and accuracy of MRI for detecting these disorders have improved^15,24,25. Furthermore, although more invasive than MRI, magnetic resonance arthrography (MRA) has been advocated to provide additional information on the intra-articular structures of the wrist²⁶. Consequentially, both MRI and MRA have been considered important investigations for the diagnosis of patients with a possible TFCC lesion to provide more information (as compared with that provided by conventional radiographic studies) on the exact location of the tear as well as on adjacent soft-tissue structures, including articular cartilage and intrinsic and extrinsic ligaments⁵. This is particularly important since ulnar-sided wrist pain can be attributed not only to injury of the TFCC, but also to abnormalities of the lunotriquetral ligament, ulnotriquetral ligament, and distal radioulnar joint^24,27.

Over the past decade, a number of studies have been done to assess the diagnostic accuracy of MRI and MRA in detecting TFCC injury by comparing imaging findings to surgical findings. While a previous meta-analysis has assessed this topic on the basis of Level-II to IV evidence, it did not differentiate between MRI and MRA with different field strengths or include an assessment of unpublished or foreign-language studies, thereby permitting publication and selection bias²⁸. We are not aware of any study in which the diagnostic accuracy of this imaging measurement specifically for the TFCC was evaluated under meta-analysis conditions with the authors accounting for these factors. The purpose of the present study was to evaluate the diagnostic accuracy of MRI and MRA in the detection of TFCC injury in the adult population.

Materials and Methods

Literature Search

The search was conducted on August 1, 2010, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations²⁹. The primary search was of the electronic databases: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register; the Cochrane Central Register of Controlled Trials (in The Cochrane Library); MEDLINE; EMBASE; AMED; BioMed Central; CINAHL (Cumulative Index to Nursing and Allied Health Literature); and Zetoc. These were reviewed from their inception date to the search date. A second search was conducted to capture unpublished or grey literature with use of the databases OpenSIGLE (System for Information on Grey Literature in Europe), WHO (World Health Organization) International Clinical Trials Registry Platform, Current Controlled Trials, UKCRN (United Kingdom Clinical Research Network) Portfolio Database, NTIS (National Technical Information Service), and UK NRR (National Research Register) Archive. The Boolean operators and MeSH and keyword search terms adopted are presented in Table E-1 of the Appendix. These were adapted for each electronic search platform.

The reference lists of all potentially relevant papers were scrutinized for any omitted studies. All corresponding authors of each included study were contacted. Each was asked to review the results of the search strategy in order to verify that, to their knowledge, all potential eligible papers had been included in the review and, if they had not been, to identify any missing studies to be added. In total, five authors of five different papers responded. No additional citations were identified by these authors for incorporation into the review.

Inclusion/Exclusion Criteria

All studies of diagnostic test accuracy that directly compared, within-study, the results of MRI or MRA (the index test) with either arthroscopic or open surgical findings (the reference test) for TFCC injury or pathology were included. Arthroscopy allows direct visualization of intra-articular structures and is therefore the most appropriate gold-standard reference test against which to assess an imaging measurement¹⁴. All study designs were eligible. English and all foreign-language publications were included in the review. Studies of cadavers, animals, and children were excluded. We did not exclude studies on the basis of methodological quality.

Sample Selection

One reviewer (T.O.S.) independently reviewed the titles and abstracts retrieved with the search strategy. The titles of potentially eligible studies were then reviewed independently by two assessors (T.O.S. and B.D.). The full texts of each potentially eligible study were then retrieved and reviewed a second time by the two reviewers (T.O.S. and B.D.) for possible inclusion in the final review.

Data Extraction

All data from English-language studies were extracted by one reviewer (B.D.) and were independently verified by a second reviewer consecutively (T.O.S.). A different reviewer (C.J.-H.) extracted the data from all studies published in German. No articles in languages other than German and English were identified. The data extracted included the sample size; average age and sex distribution of the cohort; type of MRI or MRA procedure; type of surgical procedure; and frequencies of true-negative, true-positive, false-negative, and false-positive findings. When insufficient data were available, attempts were made to calculate these data by using summary estimates. If that was not possible, the corresponding author of the article was contacted and asked to provide the raw data for true-negative, true-positive, false-negative, and false-positive results in order for these data to be incorporated into the review. In total, four corresponding authors were asked for additional data; one⁵ responded and provided data for inclusion in the meta-analysis.

Methodological Quality

The methodological quality of each included study was assessed with use of the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) form, a reliable and valid critical appraisal tool that assesses the methodological quality of diagnostic test accuracy studies^30,31. The QUADAS assessment was undertaken by one reviewer (B.D.) and was independently verified by a second reviewer (T.O.S.), with the exception of publications in German, which were appraised by a single reviewer (C.J.-H.).

Data Analysis

Analysis was conducted by one reviewer (T.O.S.). Two-by-two tables of true-positive, false-positive, false-negative, and true-negative values formed the basis of the sensitivity and specificity calculation, with 95% confidence intervals calculated for each study. A forest plot was constructed to depict these results.

Study homogeneity was first assessed visually on the basis of observed differences between study characteristics and methodologies in the data extraction tables. Second, the forest plots were examined for substantial difference in sensitivities and specificities to evaluate statistical heterogeneity. Studies that demonstrated considerable heterogeneity were excluded from the meta-analysis. For all other studies, the sensitivities and specificities formed the basis of a summary receiver operating characteristic (ROC) plot, with use of the Littenberg and Moses linear regression model³². Pooled sensitivity and specificity values for MRI and MRA techniques were constructed with use of the formulae suggested by Deeks³³. On the basis of these assessments, we compared the diagnostic test accuracy of MRI with that of MRA to detect complete (full-thickness) TFCC tears. Finally, we planned to assess the pooled sensitivity and specificity values for partial-thickness TFCC tears.

A covariate analysis was performed to assess MRI and MRA studies undertaken at field strengths of 1.0 T (MRA) compared with 1.5 T (MRI and MRA), compared with 3.0 T, to determine whether this factor had an impact on diagnostic test accuracy.

Source of Funding

There was no external funding source for this study.

Results

Search Results

The search results are presented in Figure 1. In total, 3581 citations were initially identified, and seventy-four of them were deemed potentially relevant. On full review of the twenty-seven studies that initially satisfied the eligibility criteria, four were excluded because they did not provide sufficient data for meta-analysis after attempts were made to contact the respective corresponding authors^24,34-36, one paper did not present the results of the TFCC assessment³⁷, and one paper³⁸ was a dual publication to a second paper³⁹. In this final case, only the earlier publication was included in the final review. Accordingly, twenty-one studies were included. These are summarized in Table I. Evaluation of the data extraction forms showed no substantial methodological or subject heterogeneity among the studies included in the meta-analysis.

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TABLE I Demographic Characteristics

Study	No. of Patients	No. of Wrists	Mean Age (yr)	Time from Injury to MR Study	MR Procedure*	MR Reviewers†
Braun et al.⁴²	75	75	38.3	Unclear	1.5-T MRA, frontal and sagittal. Injected into RCJ and DRUJ	2 MSK RAD
Cerofolini et al.⁵⁵	26	26	35	Unclear	MRI, unclear	Unclear
De Smet⁶⁴	35	35	33	Unclear	MRI, unclear	MSK RAD
Gabl et al.⁶⁵	32	32	27	Unclear	MRI static and MRI dynamic	Unclear
Golimbu et al.²⁵	35	35	33	Unclear	0.5-T MRI (n = 19) or 1.5-T MRI (n = 16), coronal and axial	Unclear
Haims et al.²²	86	86	37.5	Unclear	1.5-T MRI and indirect (intravenous) MRA, coronal fast spin echo	3 MSK RAD
Johnstone et al.⁴⁰	43	43	30	Unclear	0.5-T MRI	1 RAD
Joshy et al.¹⁶	24	24	43	Unclear	1.0-T MRA, coronal, sagittal, and axial. Injected into RCJ	1 MSK RAD
Shih et al.²	27	27	22.4	Unclear	MRI, unclear	Unclear
Magee⁴¹	49	49	32	Unclear	3.0-T MRI and MRA, coronal, sagittal, and axial. Injected into RCJ	2 MSK RAD
Morley et al.⁶⁶	54	54	31	Unclear	1.5-T MRI, coronal and sagittal	2 MSK RAD
Oneson et al.¹⁰	56	56	35	Unclear	1.5-T MRI, coronal	2 RAD
Pederzini et al.¹³	11	11	35.7	18 mo	1.5-T MRI, coronal and some sagittal	Unclear
Potter et al.⁵	77	77	35.7	Unclear	1.5-T MRI, coronal and axial	1 RAD
Rüegger et al.⁶⁷	41	41	38	Unclear	1.5-T MRA, coronal and sagittal. Injected into DRUJ and midcarpal joint	2 MSK RAD
Scheck et al.¹⁹	20	20	34.7	Unclear	1.5-T MRI and MRA, sagittal. Injected into RCJ, DRUJ, and midcarpal joint	Unclear
Schmitt et al.³⁹	125	125	37	Unclear	1.5-T MRA, coronal spin echo. Injected into RCJ and midcarpal joint	Unclear
Schweitzer et al.¹⁵	15	15	Unclear	Unclear	1.5-T MRI and MRA, coronal. Injected into RCJ	2 MSK RAD
Shionova et al.¹⁸	102	102	32	Unclear	1.5-T MRI, coronal, sagittal, and axial	Unclear
Totterman et al.⁷	31	31	42	Unclear	1.5-T MRI, coronal	Unclear
Zlatkin et al.⁴⁶	18	18	Unclear	Unclear	1.5-T MRI, sagittal, coronal, and axial	Unclear

*MRA = magnetic resonance arthrography, MRI = magnetic resonance imaging, DRUJ = distal radioulnar joint, and RCJ = radiocarpal joint.
†MSK = musculoskeletal, and RAD = radiologist.

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TABLE I Demographic Characteristics

Study	No. of Patients	No. of Wrists	Mean Age (yr)	Time from Injury to MR Study	MR Procedure*	MR Reviewers†
Braun et al.⁴²	75	75	38.3	Unclear	1.5-T MRA, frontal and sagittal. Injected into RCJ and DRUJ	2 MSK RAD
Cerofolini et al.⁵⁵	26	26	35	Unclear	MRI, unclear	Unclear
De Smet⁶⁴	35	35	33	Unclear	MRI, unclear	MSK RAD
Gabl et al.⁶⁵	32	32	27	Unclear	MRI static and MRI dynamic	Unclear
Golimbu et al.²⁵	35	35	33	Unclear	0.5-T MRI (n = 19) or 1.5-T MRI (n = 16), coronal and axial	Unclear
Haims et al.²²	86	86	37.5	Unclear	1.5-T MRI and indirect (intravenous) MRA, coronal fast spin echo	3 MSK RAD
Johnstone et al.⁴⁰	43	43	30	Unclear	0.5-T MRI	1 RAD
Joshy et al.¹⁶	24	24	43	Unclear	1.0-T MRA, coronal, sagittal, and axial. Injected into RCJ	1 MSK RAD
Shih et al.²	27	27	22.4	Unclear	MRI, unclear	Unclear
Magee⁴¹	49	49	32	Unclear	3.0-T MRI and MRA, coronal, sagittal, and axial. Injected into RCJ	2 MSK RAD
Morley et al.⁶⁶	54	54	31	Unclear	1.5-T MRI, coronal and sagittal	2 MSK RAD
Oneson et al.¹⁰	56	56	35	Unclear	1.5-T MRI, coronal	2 RAD
Pederzini et al.¹³	11	11	35.7	18 mo	1.5-T MRI, coronal and some sagittal	Unclear
Potter et al.⁵	77	77	35.7	Unclear	1.5-T MRI, coronal and axial	1 RAD
Rüegger et al.⁶⁷	41	41	38	Unclear	1.5-T MRA, coronal and sagittal. Injected into DRUJ and midcarpal joint	2 MSK RAD
Scheck et al.¹⁹	20	20	34.7	Unclear	1.5-T MRI and MRA, sagittal. Injected into RCJ, DRUJ, and midcarpal joint	Unclear
Schmitt et al.³⁹	125	125	37	Unclear	1.5-T MRA, coronal spin echo. Injected into RCJ and midcarpal joint	Unclear
Schweitzer et al.¹⁵	15	15	Unclear	Unclear	1.5-T MRI and MRA, coronal. Injected into RCJ	2 MSK RAD
Shionova et al.¹⁸	102	102	32	Unclear	1.5-T MRI, coronal, sagittal, and axial	Unclear
Totterman et al.⁷	31	31	42	Unclear	1.5-T MRI, coronal	Unclear
Zlatkin et al.⁴⁶	18	18	Unclear	Unclear	1.5-T MRI, sagittal, coronal, and axial	Unclear

*MRA = magnetic resonance arthrography, MRI = magnetic resonance imaging, DRUJ = distal radioulnar joint, and RCJ = radiocarpal joint.
†MSK = musculoskeletal, and RAD = radiologist.

Fig. 1

PRISMA flow chart.

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Methodology Appraisal

The results of the QUADAS review are presented in the Appendix. The authors of all but four studies had successfully recruited a clinically meaningful cohort, identifying and describing the characteristics of patients typically seen in orthopaedic departments. An additional strength of the evidence base was that, in nineteen studies, the researchers had ensured that all patients who received the reference test (MRI or MRA) underwent the same arthroscopic assessment. Another strength was that thirteen papers documented that the reviewers of the MRI or MRA were blinded to the finding of the arthroscopic assessment, preventing bias from the reference test result. However, only three studies documented that the arthroscopic surgeon was blinded to the findings of the MRI/MRA results, and only eleven studies clearly documented that all uninterpretable findings were included in the analysis. Six studies documented the duration between the MR investigation and surgery, while only eight papers documented that the reviewer of the MR studies had access to patient information, such as the history of the complaint and the clinical presentation, during the interpretation of the MR findings, as would be available during normal clinical practice. With respect to the ability to replicate the study, fourteen articles provided sufficient information to enable repetition of the MR investigation, while twelve provided sufficient detail on the arthroscopic intervention on appraisal. Finally, although a clinically meaningful cohort was recruited in seventeen studies, only twelve provided sufficient information on the selection criteria adopted during the recruitment period, thereby limiting the replication and ability to generalize the findings to a specific patient population.

Population Characteristics

The twenty-one papers included 982 patients (982 wrists) who were available for the analysis. The mean age of the cohorts was 34.3 years, with the means ranging from 22.4 years² to 43.0 years¹⁶; the mean age was not documented in two papers. The time from the injury to the investigation was not documented in any paper except the one by Pederzini et al.¹³, who reported a duration of eighteen months.

The diagnostic test accuracy of MRI was assessed in seventeen papers and that of MRA, in eight papers. Four papers assessed both MRI and MRA. The imaging field strength was 1.5 T in fourteen papers, 0.5 T in two^25,40, 1.0 T in one¹⁶, and 3.0 T in one⁴¹. The field strength was not clear in three studies. In two studies, the diagnostic accuracy of MR methods was assessed for partial as well as complete TFCC perforations^5,42.

The reviewer assessing the MRI or MRA images was identified as a musculoskeletal radiologist in eight papers and as a radiologist in two. Ten papers did not document this variable.

Meta-Analysis

As Figure 2 demonstrates, the diagnostic test accuracy of MRA was superior to that of MRI, with the MRA plot presenting a greater area under the curve as compared with that seen on the MRI plot. The review of the data for the MRI demonstrated a pooled sensitivity of 0.75 (95% confidence interval [CI]: 0.70, 0.79), with a specificity of 0.81 (95% CI: 0.76, 0.86). The pooled sensitivity for the MRA results was 0.84 (95% CI: 0.79, 0.89), with a specificity of 0.95 (95% CI: 0.92, 0.98). This is summarized as a forest plot in Figure 3.

Fig. 2

Summary receiver operating characteristic curve demonstrating that the diagnostic accuracy of MRA was superior to that of MRI for the detection of TFCC tears.

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Fig. 3

Forest-plot comparing the diagnostic accuracy of MRI with that of MRA for the detection of complete TFCC tears. TP = true positive, FP = false positive, FN = false negative, and TN = true negative.

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Covariates

Two studies assessing the diagnostic test accuracy for partial-thickness TFCC tears were identified^5,42. Braun et al.⁴² reported a sensitivity of 0.65 (95% CI: 0.41, 0.85) and a specificity of 0.95 (95% CI: 0.85, 0.99) for their 1.5-T MRA assessment. Potter et al.⁵ assessed the accuracy of a 1.5-T MRI method and reported a sensitivity of 1.00 (95% CI: 0.83, 1.00) and a specificity of 0.90 (95% CI: 0.68, 0.99).

Data were available to assess the accuracy of two MRI field strengths from fifteen MRI studies. In a comparison of 3.0-T and 1.5-T MRI analyses, 3.0 T appeared to have a greater diagnostic test accuracy than 1.5 T (see Appendix). The 3.0-T results were extracted from a single study⁴¹, which demonstrated a sensitivity of 0.86 (95% CI: 0.65, 0.97) and a specificity of 1.00 (0.87, 1.00). In comparison, the pooled sensitivity for the 1.5-T MRI assessments was 0.70 (95% CI: 0.64, 0.75) and the specificity was 0.79 (95% CI: 0.72, 0.85).

Three MRA field strengths could be assessed as part of the covariate analysis. This showed that diagnostic test accuracy improved at greater field strengths (see Appendix). On analysis of the accuracy of 3.0-T MRA, based on the single study by Magee⁴¹, sensitivity was 1.00 (95% CI: 0.79, 1.00) and specificity was 1.00 (95% CI: 0.82, 1.00). The pooled analysis of sensitivity for 1.5-T MRA was 0.83 (95% CI: 0.78, 0.89) and the specificity was 0.95 (95% CI: 0.91, 0.98). The data on 1.0-T MRA, derived from the findings of Joshy et al.¹⁶, indicated a sensitivity of 0.79 (95% CI: 0.54, 0.94) and a specificity of 0.80 (95% CI: 0.28, 0.99).

Discussion

The findings of this study suggest that MRA is superior to MRI for the investigation of full-thickness TFCC tears. MRA showed moderate, while MRI demonstrated limited, diagnostic test accuracy for the detection of full-thickness TFCC tears. MR field strength appears to be important, with MRI and MRA images obtained at greater field strengths providing greater diagnostic test accuracy. The data were not sufficient for us to comment on the diagnostic test accuracy of MRI and MRA of partial-thickness TFCC tears. Both MRI and MRA were better at excluding a TFCC tear when one was not present (specificity) than they were at showing a TFCC tear when one was actually present (sensitivity).

This review, however, identified a number of methodological limitations. These, most importantly, included poor blinding of the reviewer of the reference standard (the arthroscopic evaluation) to the findings of the imaging technique, providing limited information on the subject selection criteria, and not documenting the duration between the imaging and the surgical confirmation. As a result, it was not possible to ascertain whether a patient’s wrist pathology deteriorated, remained the same, or improved throughout, or whether it changed between the imaging and arthroscopic investigations, which would have accounted for variation between the assessments. In the papers that did document this duration, the period ranged from three days⁴² to 3.5 months¹⁶. Therefore, it is unclear whether the time from imaging to surgery affects the validity of the findings.

In this review, we did not distinguish between the use of open surgery and the use of arthroscopic surgery as the reference standard. Some authors have suggested that an arthroscopic assessment is superior to an arthrotomy since it magnifies the wrist and allows access to all areas of the TFCC⁴³. Clinical outcomes of open repair have been compared with those of arthroscopic repair and have been reported to be similar^44,45. In our review, arthroscopy was used as the reference standard in all but two studies^25,46. Since there is no clear consensus about whether there is a difference between open and arthroscopic surgery for TFCC tears, we considered it justifiable to include these two studies in the review.

Previous authors have cited a poor correlation between the location and duration of pain and positive arthrographic findings of a TFCC tear⁴⁷. A positive arthrographic result does not necessarily indicate that the TFCC is the principal abnormality responsible for a patient’s symptoms²⁵. It is accepted that there is a higher prevalence of TFCC tears in people over the age of fifty years, with >60% of wrists in this age group exhibiting such a finding^48-50. Degenerative tears are often central in location, as the TFCC is thinner and more vulnerable to chronic stresses from the axial load force of the ulnar head^25,48. However, a lesion located in the more fibrous margin, close to the ulnar insertion, is more indicative of a symptomatic perforation requiring surgical treatment^25,51. While some authors have suggested that radiographic arthrography and MRI investigations poorly differentiate the location of TFCC tears¹³, MRA has been suggested to possess greater diagnostic test accuracy with superior visualization of the morphology and location of the TFCC lesion¹⁹. Accordingly, this may be a major advantage in terms of differentiating between TFCC lesions that do and those that do not require surgical management, particularly in patients over the age of fifty years.

There is now evidence that multidetector computed tomographic (CT) arthrography is an accurate technique for detecting intrinsic ligament tears in the wrist^52-54, but MR studies have advantages over both CT and conventional arthrography. In particular, MR studies have the ability to demonstrate other soft-tissue abnormalities that may contribute to the patient’s symptoms, such as osteonecrosis, tendon inflammation and tears, synovitis and joint fluid collections, as well as soft-tissue masses^{5,10,16,24,41}. This is a major advantage as ulnar-sided wrist pain can be attributed to multiple causes²⁴. The ability to assess these other sources of pain makes MR studies, which are less invasive than arthroscopy, preferable to radiography, particularly for patients over the age of fifty years, in whom a tear in the TFCC may be evident but not the principal source of symptoms.

False-positive findings on MRI, such as infolding of the TFCC when the TFCC is abnormally thin and stretched, have been reported²⁵. In order to prevent false-positive results, Golimbu et al.²⁵ recommended reducing the imaging section thickness from 5 to 3 mm and positioning the wrist in maximum radial deviation to stretch the TFCC. We are not aware of any studies in which the importance of imaging section thickness or the position of the wrist has been assessed as possible variables confounding diagnostic test accuracy. In contrast to Golimbu et al., Potter et al.⁵ recommended positioning the wrist relative to the long axis of the magnetic field to minimize the incidence of artifact with increased signal intensity. Further study is warranted to determine whether these factors are important in optimizing the diagnostic accuracy of MRI or MRA.

There remain technical issues involved in the interpretation of MRI and MRA. Haims et al.²² acknowledged that the interpretation of findings of MR examination (MRI and indirect MRA) of the wrist, compared with larger joints, depends on image quality. This can be compromised by patient motion, poor fat suppression, or metallic artifact from orthopaedic implants^22,26,55,56. The studies included in the present review often did not identify the experience of the radiologists involved, with only eight studies differentiating whether the radiologists were specifically musculoskeletal radiologists. Since the experience of the radiologists has been suggested as a factor in variation in diagnostic accuracy of MRI and MRA^16,57,58, this important consideration should be addressed when future studies are designed. Similarly, the technical skills and interpretative abilities of the arthroscopic surgeon may also have been an important confounding variable in the studies included in this review. Wrist arthroscopy is acknowledged to be a technically demanding procedure^59-62. The studies included in our review were generally poor at documenting the arthroscopic experience of the clinicians who acted as the reference standard. Therefore, this, in addition to the experience of the reporter of the MRI or MRA findings, must be taken into account when one considers the strength of our findings in this review. Finally, the specific arthroscopic technique may also have been a confounding variable. We included all studies in which open or arthroscopic procedures were used as the “reference test.” However, it was not always clear from the literature whether the arthroscopic procedure included a separate portal into the distal radioulnar joint in addition to the volar ulnar portal. If it did not, partial-thickness TFCC tears involving the proximal surface of the TFCC may have been missed^60,63, thereby bringing into question the validity of these arthroscopic procedures in the detection of partial-thickness TFCC tears.

There was some variability in the MRA technique employed in the studies. As Table I demonstrates, a single-compartment injection technique was used in two studies^15,41 while a variety of compartment-injection combinations were utilized in the other four MRA studies. We did not assess whether there is a difference in diagnostic accuracy among single, double, and triple-compartment-injection techniques, and currently there are insufficient data to perform such a subgroup analysis.

Although the superiority of MRA over MRI must be acknowledged, there are some disadvantages of using MRA instead of MRI for patients with a suspected TFCC lesion. These include the additional cost, the invasiveness, and the need for contrast material for injection into joints¹³. As a result, as Scheck et al.¹⁹ reported, the procedure is both technically complicated and more time-consuming than conventional MRI. Given that the difference in the diagnostic test accuracies of the two tests was only marginal, it may be argued that this small difference does not justify the use of the more invasive MRA for all suspected TFCC lesions. Although MRA has a higher test accuracy, this improvement in diagnostic performance may not be large enough for some clinicians to see a change in clinical outcomes if they change their practice from using MRI to employing MRA.

Arthroscopy is effective in the diagnosis and localization of TFCC lesions. However, it is more expensive than MRI^5,18 and more invasive than MRA. Given the moderate diagnostic test accuracy of MRA, it has been suggested that, while arthroscopic surgery may be able to guarantee confirmation of the status of the TFCC, it may not be cost-effective when the subsequent management can be predicted prior to surgery¹³. For certain clinical presentations, arthroscopy, which provides both diagnostic and therapeutic outcomes in one episode, may be preferable to separate diagnostic and therapeutic stages. However, it was not the purpose of this review to compare the costs and benefits of arthroscopy with those of MR investigations.

In conclusion, MRA is a moderately accurate assessment method for patients who present with the signs and symptoms of a full-thickness TFCC injury. The diagnostic test accuracy of MRA was superior to that of MRI on systematic review, with MRI having limited diagnostic test accuracy. However, the published evidence base contains a number of methodological limitations. We therefore cautiously recommend that, in cases in which there are questions about the diagnosis and subsequent management of patients with ulnar-sided wrist pain, the available literature supports the use of an MRA in preference to standard MRI to establish a diagnosis of TFCC.

Appendix

Tables showing the search strategy and the results obtained with the QUADAS (appraisal) tool as well as figures showing the summary receiver operating characteristic curves for the effects of field strength on the diagnostic accuracy are available with the online version of this article as a data supplement at jbjs.org.

Acknowledgements

Note: The authors thank the library staff at the University of East Anglia for their assistance in gathering the papers used in this study. They also thank all corresponding authors who reviewed the results of this study’s search strategy.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

aspirin ; magnetic resonance angiography ; arthrogram ; wrist ; vibration ; triangular fibrocartilage complex of the wrist

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Toby O. Smith, Benjamin Drew, Andoni P. Toms, Christina Jerosch-Herold, Adrian J. Chojnowski; Diagnostic Accuracy of Magnetic Resonance Imaging and Magnetic Resonance Arthrography for Triangular Fibrocartilaginous Complex InjuryA Systematic Review and Meta-Analysis. The Journal of Bone & Joint Surgery. 2012 May;94(9):824-832.

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