Graesser Elizabeth A, Wall Lindley B, Kakar Sanjeev, Yao Jeffrey, Richard Marc J, Gaston R Glenn, Goldfarb Charles A
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA.
J Hand Surg Am. 2025 Jan;50(1):2-9. doi: 10.1016/j.jhsa.2024.07.002. Epub 2024 Aug 9.
Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos.
Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients.
The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round.
Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy.
This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears.
腕关节镜检查被认为是诊断包括三角纤维软骨复合体（TFCC）撕裂在内的关节内腕部疾病的金标准；然而，在腕关节镜检查期间可靠诊断TFCC病变的能力尚不清楚。本研究的目的是评估腕关节镜检查视频中TFCC撕裂诊断的可靠性。
五位手外科医生在一个安全的基于网络的平台上，于两个相隔4 - 6周的时间点对43例病例进行了评估。每个病例包括一份匿名的临床病例摘要、带有尺骨变异测量值的腕部X线片以及一段平均时长42秒的尺侧腕部病变的关节镜检查视频。向外科医生询问TFCC撕裂的存在情况以及帕尔默（Palmer）和阿泽伊（Atzei）分类。使用kappa系数确定观察者间/观察者内的可靠性。
关于TFCC撕裂是否存在的观察者间可靠性为中等偏上，第一轮病例评估的kappa系数为0.596，第二轮为0.708。TFCC撕裂是否存在的总体观察者内可靠性也为中等偏上，kappa系数为0.567。对于中央TFCC撕裂的病例，关于TFCC撕裂存在情况的观察者间可靠性极佳，kappa系数为1.0。排除中央撕裂后，每轮的kappa系数分别降至0.322和0.368。帕尔默和阿泽伊分类的观察者间可靠性较低，第一轮的kappa系数为0.220和0.121，第二轮为0.222和0.123。
经验丰富的腕关节镜外科医生在腕关节镜检查中对TFCC撕裂的诊断表现出中等偏上的观察者间可靠性。然而，如果排除中央TFCC撕裂，观察者间可靠性较差。这些发现表明需要关注腕关节镜解剖学的教育。
除中央TFCC撕裂外，本研究表明外科医生在TFCC撕裂的识别和分类方面一致性较差。低可靠性对TFCC撕裂的治疗考量有直接影响。
