MR imaging interpretation of the Palmer classification of triangular

MR Imag#{252}g Interpre#{149}:::::
tation ofthe
Palmer
au
s:::
.
::
.
Classification
of
Trian-
gular
Fibrocartilage
Complex
Lesions1
Susan
R. Oneson,
MD
Lisa M Scales,
MD
Michael
E. Timins,
MD
Scottj
Erickson,
MD
Lewis
Chamoy,
MD
The
triangular
fibrocartilage
biomechanical
nar
I
wrist
TFCC
The
may
TFCC
are
lesions
This
are
sions.
than
contribute
cause
in its horizontal
In the
to the
in determining
arthrography
accurately
Traumatic
of the
extent
structural
pain.
are
U INTRODUCTION
The distal radioulnar
angular
fibrocartilage
this
joint
complex
Index
terms:
RadloGraphics
i
I
been
GRE
Wrist,
1996;
detected
joint is composed
complex
(TFCC).
extensively
movement
Abbreviations:
:
have
reliably
while
gradient
434.92
echo,
#{149}
Wrist,
of the distal
The complex
explored
preserving
TFC
=
injuries,
with
over
stability
triangular
434.483,
434.77
MR
the
past
transmitting
#{149}
Wrist,
le-
presence
or ab-
and is
cases
of
imaging.
radioulnar
anatomy
TFCC
and
may
of TFCC
classification
only advanced
and
fibrocartilage,
imaging
abnormalities
The
sence
of chondromalacia
is a factor
in the Palmer
also considered
in treatment
planning.
However,
chondromalacia
of injury
(MR)
evaluation
the
and
degenera-
mechanism
in prospective
instability
injury;
le-
of degeneration.
resonance
demonstrate
to ulnocarpal
in its
or degenerative.
the
Magnetic
portion,
classifIcation,
to the
and
of ul-
Palmer
location
according
is helpful
MR images
that
anatomic
is a recognized
injured
according
management.
useful
is a complex
TFCC
as traumatic
subclassified
clinical
more
be
categorized
classification
directing
(TFCC)
to the
or at its attachments.
are subclassified
tive
be
Injury
portions,
lesions
sions
:
pain.
peripheral
complex
structure.
few
=
articulation
and
and biomechanics
years.
triangular
This
axial
joint
the
triof
permits
load.
fibrocartilage
complex
MR. 434.12141
16:97-106
I From
53226
entific
the Department
of Radiology’,
Froedtert
Memorial
Lutheran
Hospital,
9200 W Wisconsin
Ave. Milwaukee,
WI
(S.R.O.,
L.M.S.,
MET.,
S.J.E.);
and Hand
Surgery
Ltd. Milwaukee
(L.C.).
Recipient
of a Cum Laude
award
for a sci
exhibit
at the 1994 RSNA scientific
assembly.
Received
February’
28, 1995;
revision
requested
March
21 and re-
ceived
June
c RSNA,
5: accepted
June
6. Address
reprint
requests
to S.R.O.
1996
97
Exclusion
of the ulna from the carpal
articulation
by the addition
of a ligamentous
interposing structure-the
TFCC-is
one of the evolutionary
factors
that distinguish
hominids
from
more
primitive
species.
The articular
disk is
centrally
fenestrated
in all species
except
Homo
has
sapiens,
been
in whom
postulated
that
the
disk
the
isolation
is intact.
It
of the
ulna was necessary
to create
the rotational
ability needed
for tree swinging
or brachiation
(1).
The TFCC can be thought
of as a cushion
between
the carpus
and the ulnar head.
Injury
to
the TFCC is a common
cause
of ulnar wrist
pain. Palmer
(2) devised
a classification
system
for TFCC lesions
that is based
on the cause,
1cation,
and extent
of the injury.
This classification
system
has
been
weli
received
and
has
sig-
nificant
implications
for treatment
planning.
In this article,
we briefly
review
the anatomy
and MR imaging
appearance
of the normal
TFCC. We then describe
the Palmer classification and illustrate
the pertinent
MR imaging
findings
jury.
in surgically
Finally,
we
of MR imaging
TFCC
proved
discuss
and
cases
the
of TFCC
relative
arthrography
the poorly
defmed,
loosely
textured
ulnar collateral
ligament.
The meniscal
homologue
has
no independent
histologic
identity.
Volarly,
the
TFC is attached
to the lunotriquctral
ligament,
which
is not considered
part of the TFCC, and
to the triquctrum
via the ulnotriquetral
ligament.
There
is weaker
and inconstant
attachment to the lunate
via the ulnolunate
ligament.
The TFCC has three
main functions:
(a) The
central
fibrocartilaginous
portion
absorbs
20%
of the axial or compressive
load transmitted
across
the
80%
(5,6). (b)
radioulnar
the
dorsal
wrist.
in-
absorbs
radioulnar
ligaments
extend
from
the
for
the
ulnocarpal
joint.
The
ulnolunate
palmar
efficacies
in diagnosis
of
lesions.
U
MR
IMAGING
APPEARANCE
NORMAL
TFCC
In a normal
TFCC,
the
OF
articular
disk
THE
(the
TFC)
TFCC
articular
disk (the triangular
fibrocartilage
[TFC]
proper),
the dorsal
and palmar
radioulnar
ligaments,
the meniscal
homologue,
the strong
sheath
of the ulnar cx-
appears
as a thick band of low signal intensity
with all pulse sequences.
The disk appears
biconcave
in the sagittal
plane;
the peripheral
tensor
has
tendon,
the
ulnar
collateral
ligament,
and the two ulnocarpal
ligaments
(the ulnolunate
and ulnotriquetral
ligaments)
(Fig ia).
The TFC attaches
to the hyaline
cartilage
of
the radius
and inserts
into the ulnar fovea.
It attaches
broadly
to the ulna between
the articular
cartilage
on the head and at the tip of the stybid
process.
The
dorsal
ligaments
strengthen
attaching
uncalcified
to the radius
fibrocartilage
ply
TFC
of the
volar
aspects.
l0%-40%
arises
volar
radial
the
penetrate
TFCC,
leaving
are
central
zone.
much
thicker
The
a striated
and
ulnar
stronger
than
attachment
appearance
on
of the
MR
images
the
TFC
(Fig
ib). The meniscal
homologue
and the associated ulnar extensor
tendon
subsheath
and ulnar
collateral
ligament
are not consistently
seen at
MR imaging.
However,
the ulnotriquetral
and
ulnolunate
(Fig
ligaments
can
be
clearly
visualized
ic).
radioulnar
attachment
via zones
of calcified
(3). The vascular
from
Vessels
of the
and
the
margins
ulnar,
only
the
by
and
sup-
dorsal,
and
the
outer
central
and
a PATHOLOGIC
CONDITIONS
OF THE
TFCC
.
Clinical
Experience
During
1992 and 1993, the TFCC was evaluated
with arthroscopy
or arthrotomy
in 59 adult patients
at our
institution.
MR
imaging
of these
radial portions
avascular
(4). This vascular
distribution
may play a role in degenerative
lesions
and has an effect
on healing,
as in tears of the
knee menisci.
The meniscal
homologue
is an ill-defined
region of dense,
irregular
fibrous
tissue.
A continuation
of the articular
disk, it blends
with the
patients
was performed
with a 1 .5-T system
(GE
Medical
Systems,
Milwaukee,
Wis) and a homemade single-turn
solenoid
coil 4 inches
(10 cm)
sheath
30#{176}
flip
of the
ulnar
extensor
tendon
and
with
in diameter
density
etition
70)
and
Exhibit
4 inches
long.
or T2-wcighted
time
and
time
gradient-echo
two
signals
ness
with
=
images
with
(rep-
2,200/16,
(600/17,
a 256
x
field ofview,
one or
and a 3-mm
section
thick-
an 8-cm
averaged,
a 0.5-mm
obtained
spin-
images
msec
(GRE)
were
matrix,
Coronal
spin-echo
msec/echo
angle)
192-224
Scientific
joint
and ulnotriquetral
ligaments
prevent
subluxation
of the ulnar carpus.
ANATOMY
OF THE
The TFCC consists
of the
U
radiocarpal
volar and dorsal
rims of the sigmoid
notch
to
the fovea and base of the ulnar styloid
process.
The major
function
of these
ligaments
is to prevent volar and dorsal
subluxation
at the distal
radioulnar
joint (6). (c) The TFCC provides
stability
U
98
The
The TFCC is a major
stabilizer
of
joint (6). The thick palmar
and
gap.
Sagittal
Volume
Ti-weighted
16
Number
1
a.
b.
Figure
1.
Normal
TFCC.
(a) Diagram
shows
the ligamentous
supports
of the ulnar aspect
of the wrist (the TFCC)
from a
dorsal
perspective.
Not shown
are the ulnar collateral
liga-
ment,
the meniscal
subsheath,
and
homologue,
the
volar
spin-density
MR
of the ulnar
lunotriquetral
attachment
ligament,
tal Ti-weighted
the
image
shows
the
normal
shows
ligaments
extensor
ligament.
the
tendon
(b)
Coronal
striated
of the TFC. ad
mh = meniscal
MR image
ulnocarpal
the ulnar
radioulnar
appearance
articular
homologue.
disk,
=
normal
it =
Sagit-
(C)
appearance
of
(u).
0.5-mm
gap for evaluation
of the ulnocarpal
ligaments.
The MR images
were retrospectively
read by
two musculoskeletal
radiologists
(M.E.T.,
Sj.E.)
blinded
to the surgical
fmdings.
This reading
was
C.
Palmer
of TFCC
ClassifiCation
I. Traumatic
Lesions
injury
A. Central
perforation
B. Ulnar avulsion
C. Distal
D. Radial
avulsion
avulsion
II. Degenerative
A. TFC wear
B. TFC wear
performed
.
injury
Palmer
Injury
nar
and chondromalacia
and
E. TFC perforation,
lunotri-
lesions
ulnocar-
(class
quetral
ligament
pal/radioulnar
images
perforation,
arthritis
luno-
study
and
(500/20)
were obtained
with a 256 x
matrix,
an 8-cm field of view,
two signals
averaged,
and a 3-mm section
thickness
with a
224
January
1996
of another
imaging
pro-
clarify
Classification
to the
wrist
TFCC
pain.
tion system
on a review
C. TFC perforation
and
chondromalacia
D. TFC perforation,
chondromalacia,
triquetral
ligament
perforation
chondromalacia,
as part
ject (7). The surgical
report,
clinical
information, and MR imaging
appearance
were used to
categorize
the TFCC according
to the Palmer
classification.
MR images
of arthroscopically
proved
TFCC injuries
that show
the characteristic findings
in each category
are presented
later
in this article.
(2)
as traumatic
II) (Table).
locus
with
wrist
(class
cause
proposed
for TFCC lesions,
of the literature
of patients
the
is a recognized
Palmer
of ul-
a classi.fica-
which
was based
and a retrospective
pain.
He
classified
D or degenerative
Further
subdivision
of injury
in traumatic
serves
to
lesions
and the cumulative
derangement
of the TFC in
degenerative
lesions.
This classification
is helpflu in determining
the mechanism
of injury
and
directing
clinical
management
(8).
Oneson
et al
U
RadioGraphics
U
99
a.
b.
Figure
2.
Class IA lesion.
the TFC.
(b) Coronal
GRE
signal-intensity
radial
(a)
Diagram
MR image
hyaline
shows
shows
cartilage
for
a dorsal-palmar
a class
a slitlike
slitlike
IA tear (arrow).
tear
Care
(arrow)
must
medial
be taken
to the
radial
not to mistake
origin
of
the high-
tear.
a.
b.
Figure
3.
Class lB lesion.
(a) Diagram
shows
avulsion
of the TFC at the peripheral
ulnar attachment
(arrow).
(b) Coronal
T2-weighted
MR image shows a focus of high signal intensity
that represents
a tear at the ulnar
fovea (arrow).
Contrast
this abnormal
high signal intensity
with the alternating
bands
of low and high signal intensity
.
that
Class
can
be seen
I Lesions
Class
IA lesions
tions
of the TFC
sagittally
oriented,
are
at the
ulnar
attachment
of the
(Traumatic)
traumatic
proper.
slitlike
tears
These
tears
or perfora-
1 -2-mm-long,
arc
located
ap-
normal
TFC
(Fig ib).
proximately
2-3 mm medial
to the radial aspect
of the TFC (Fig 2). Occasionally,
there
is a flap
of redundant
cartilage
along the palmar
aspect
of the TFC. Because
these
tears occur
in the
avascular
portion
of the
and are usually
treated
loose flap tissue
(9).
100
U
Scientific
Exhibit
TFC,
with
Volume
they
do
not
d#{233}bridement
16
heal
of all
Number
1
5a.
5b.
Figures
4, 5.
(4) Class IC lesion.
Diagram
shows
disof the TFCC from its osseous
insertions
on
and triquetrum
(arrows).
(5) Class ID lesion.
Diagram
shows
avulsion
of the TFCC from its radial
tal avulsion
the lunate
(a)
attachment
(arrows).
age shows
ment
and
Class
(b)
Coronal
abnormal
signal
in the radioulnar
IC lesions
spin-density
MR
are
traumatic
im-
radial
intensity
at the
joint (arrows).
attach-
avulsions
of
the peripheral
volar attachments
of the TFCC,
specffically
the ulnolunate
or ulnotriquctral
ligament (Fig 4). In our series
of 59 wrists,
no surgically
proved
These
lesions
stability
with
class
IC lesions
frequently
palmar
were
result
identified.
in ulnocarpal
translocation
of the
inlunate
or triquetrum.
Surgical
repair
is usually
attempted
in cases of acute
or subacute
lesions.
An ulnar
shortening
osteotomy
to tighten
up
the ulnocarpal
ligaments
is reserved
for chronic
lesions
(9).
4.
Class
Class
lB lesions
are
traumatic
avulsions
of
the TFC from its attachment
site on the ulnar
fovea (Fig 3). Fracture
through
the base of the
ulnar
styloid
process
may accompany
the TFC
avulsion.
These
jury to the
ments
and
instability.
lesions
palmar
therefore
Class
well-vascularized
and
arc
associated
with
in-
dorsal
radioulnar
ligaoften result
in radioulnar
lB lesions
periphery
are
and
but some surgeons
have begun
tears using a modified
meniscal
located
thus
ID lesions
are
traumatic
avulsions
of
the radial attachment
of the TFC in the region
of the sigmoid
notch
(Fig 5). They may be accompanied
by distal radial fractures.
The radial
attachment
is relatively
avascular
and therefore
heals poorly.
These
lesions
are less common
than class IA and lB lesions
and are currently
treated
with d#{233}bridement.
in the
may
heal,
repairing
these
repair
system
(9).
January
1996
Oneson
Ct
al
U
RadioGraphics
U
101
6a.
6b.
7a.
Figures
Th.
6, 7.
shows
wear
(b) Coronal
(6) Class hA lesion.
of the central
portion
GRE MR image shows
(a) Diagram
of the TFC (arrow).
an intact but subtly
thinned
TFC. (7) Class IIB lesion. (a) Diagram
shows
wear of the central portion
of the TFC and lunate
chondromalacia
GRE (c) coronal
ened
C =
lunate
lunate
(arrows).
(b, c) Spin-density
MR images
show
abnormally
cartilage
with
an intact
but thinned
(b) and
thick-
TFC.
chondromalacia.
7c.
102
U
Scientific
Exhibit
Volume
16
Number
1
Figure
8.
Class IIC lesion.
(a) Diagram
shows
a
large, central
TFC perforation
and abnormality
of the
lunate
cartilage
(arrows).
(b, c) Spin-density
(b) and
GRE (c) coronal
MR images
show
a central
TFC perforation
(large
arrow).
The thin line of low signal intensity represents
abutment
of ulnar cartilage
against
lunate cartilage,
not a very thinned
but intact
TFC. Note
the intact
lunotriquetral
ligament
(small
arrow).
no perforation
class
IIB lesions
is present
in our
Class
H Lesions
(Degenerative)
(Fig
7). In the
only
advanced
Class
IIC
lesions
are
IIC lesions
arc usually
spectrum
of the
and
of degenerative
change.
Along
with
characterized
by further
degenerative
change
with frank
perforation
of
the TFC (Fig 8). The perforation
is located
in
the central,
avascular
portion
of the TFC. These
perforations
tend to be oval rather
than slitlike.
Chondromalacia
is not commonly
appreciated
on MR images,
as shown
in Figure
8. When
visiblc, it typically
appears
as areas of abnormal
Class hA lesions
involve
degenerative
wear or
thinning
of the articular
disk without
perforation (Fig 6). As with all degenerative
TFC lesions,
class HA lesions
are the result
of chronic
axial
forces
on the wrist and are more commonly
seen with ulnar
variance.
Fraying
of the
proximal
or distal aspect
of the TFC may be
seen at arthrography
or arthroscopy.
Class JIB lesions
involve
progression
of the
TFC
study,
cases of surgically
proved
chondromalacia
were
reliably
detected
prospectively
with MR imaging. Class ILk and IIB lesions
are managed
conservatively,
by d#{233}briding the worn
areas,
or
with ulnar
decompression
(shortening)
(9). Ulnar surgery
is usually
reserved
for cases with
chondromalacic
change
(9).
C.
.
but
signal
intensity,
TFC
irregularity,
ulnar
and
treated
with
decompression
thinning.
Class
d#{233}bridement
(9).
thinning,
chondromalacia
of the lunate,
triquetrum,
or distal
nina is present.
The TFC
wear is more advanced
than in class hA lesions,
January
1996
Oneson
et al
U
RadioGraphics
U
103
a.
b.
Class
Figure
9.
lunotriquetral
lID lesion.
ligament
(a) Diagram
disruption
(large arrow).
Note the tapered
contrast
to the square, straight
normal U-shaped
lunotriquetral
Class
IIC lesions
quetral
Such
the
a lesion
a large
(b)
Coronal
of the TFC
appearance
margins
of a traumatic,
ligament
(small arrow).
from class
of lunotri-
Class
and
comprise
large
chondromalacia,
central
ulnar
lunotriquetral
were
ulnocararthritis
result
of
of
class
with d#{233}brideis present,
a
be
required
study,
MR imaging
for detection
and
detected
decreased
had cx-
of central
radial-sided
one of four
was
by the other.
for
detection
degen-
slitlike
perfora-
prospectively
Many studies
arthrography
(9).
three-phase
However,
of ulnar
surgically
proved
accuracy
avulsions:
ulnar
Only
avulsions
detected
by each reader.
have attempted
to correlate
performed
compartment
If suffi-
is present,
may
on
portion
absent.
can be treated
If no ligament
arthrodesis
TFC
impaction)
the central
completely
ligament
LID and lIE lesions
ment and pinning.
lunotriquetral
cases,
(ulnar
and
tions,
with a high interobserver
correlation.
All
1 5 central
degenerative
perforations
and all
seven
radial-sided
slitlike
perforations
were
detected by one reader;
1 4 of 1 5 and six of seven
lunotriquetral
loading
chondromalacia,
the TFC perforation
DISCUSSION
In our retrospective
defects
the wrist. In these
the TFC is usually
cient
.
erative
TFC
lunate
shows
at the edges of the perforation.
This appearance
is in
slitlikc tear (class IA lesion). Also note the absence
of the
chondromalacia
constellation
of surgical
fmdings.
results
in lunotriquetral
instabil-
lIE lesions
axial
perforation,
MR image
accuracy
ligament
disruption,
and concomitant
pal and occasionally
distal radioulnar
(Fig 10). Such a lesion
is the end-stage
chronic
TFC
spin-density
cellent
(Fig
ity.
perforations,
central
9). A thinned,
perforation
perforated
complete
(arrows).
lID lesions
are distinguished
by the additional
presence
ligament
centrally
shows
with
injection
injection
with
technique
single-
or triple-
arthroscopy.
was
The
designed
to minimize
false-negative
results in cases with
flap tears or one-way
valves. Using injection
into the distal radioulnar
found
tears of the TFCC
were
not seen
with
joint, Belsole
in 1 3 patients;
radiocarpal
et al (10)
the tears
injection
in
seven cases.
Five of the 1 1 tears seen with radiocarpal
injection
were
not seen with radioulnar joint injection.
In 75 cases of complete
TFCC
104
U
Scientific
Exhibit
defects,
Levinsohn
et al (1 1) diagnosed
Volume
16
Number
1
a.
b.
Figure
Class lIE lesion. (a) Diagram
shows a large central TFC perforation,
chondromalacia
and ulnar head, lunotriquetral
ligament
disruption,
and osteophyte
formation
at the radioulnar
nal GRE MR image shows absence
of the central
portion
of the TFC (straight
arrows),
absence
quetral
ligament
with separation
of the lunate and triquetrum,
irregularity
of lunate
and
ulnar
10.
osteophytes
only
at the
two
radioulnar
additional
joint
defects
joint injection.
In a study
TFCC perforations
were
mined
with
radiocarpal
approaches
with
75%,
et al (i 1).
studies have
Fewer
missed
Note
radioulnar
on images
alone.
no
oh-
How-
radiocarpal
according
attempted
injec-
to
to correlate
Zlatkin
et al
(13) found
that tears of the TFCC were
detected equally well with MR imaging
and with
arthrography
performed
with both radiocarpal
and three-compartment
injection.
Cerofolini
et
al (14)
found
only one additional
tear of the
TFCC with arthrography
that was not seen at
MR imaging
with
MR imaging
of 10 surgically
In studies
arthroscopy,
arthrography
(1 5) found
that
arthrography.
compare
the high
that
proved
false-negative
figures
prominently.
TFCC lesions
were
pletely
diagnosed
January
1996
tears.
arthrography
preoperatively
the
ulnar
lunate
(b) Coro-
of the
lunotri-
cartilage,
and
variance.
patients.
(12),
partial perforation
of the
abnormality,
the rate of
diagnosis
tion alone
Levinsohn
with
arrow).
by Manaster
injection
ever, if one includes
TFCC as a significant
false-negative
(curved
of the
joint.
with
rate of
In a study by Roth and Haddad
(16),
of 37 confirmed
TFCC lesions
were
identified
with arthrography.
The study
of
Vanden
Eyndc
et al (17) showed
a 52% sensitivity and
50% specificity
for TFCC lesions
when
arthrography
was performed
with radiocarpal
injection.
Their results
yielded
a positive
predictive
value of 92% and a negative
predictive
value of 8%.
On the basis of these
fmdings
and the fact
that several
studies
have shown
poor correlation between
the site of the arthrographic
defeet and the patient’s
symptoms,
we believe
that arthrography
is useful
only in confirming
the clinical
diagnosis.
When
arthrography
is
used for this purpose,
arthroscopy
is indicated
whether
or not the arthrogram
is positive.
We
believe
that MR imaging
can supplant
arthrogonly
70%
raphy
onstrates
because
it is noninvasive,
perforation
of the
accurately
TFCC,
and
dem-
allows
Koman
et al
incomin 62% of 53
Oneson
et al
U
RadioGraphics
U
105
assessment
of other
potential
patient’s
symptoms,
perhaps
copy in certain
cases.
. CONCLUSIONS
The TFCC is a complex
this
ligamentous
complex
causes
obviating
of the
planning.
Linscheid
7.
dioulnar
Oneson
structure,
and injury
is responsible
for
MR imaging
2.
3.
5.
The
distal
of the wrist.
Bednar
MS, Arnoczky
crovasculature
of the
J Anat
1990;
12.
radioul-
14.
mi-
U
Scientific
Exhibit
Arthroscopic
.
Chin
treat-
1991
TL, Beatty
; 7:277ME,
Rayhack
JM.
Digital
subtraction
arthrography
of the wrist. J Bone Joint Surg [Am] 1990; 72:
846-851.
Levinsohn
EM, Rosen
ID, Palmer
AK.
Wrist
arthrography:
value of the three-compartment
injection
method.
Radiology
i99i;
179:231239.
Manastcr
BJ.
The
clinical
efficacy
of triple-in-
jection
wrist
arthrography.
Radiology
1991;
178:267-270.
Zlatkin
MB, Chao PC, Osterman
AL, et al.
Chronic
wrist
pain: evaluation
with high.rcsolution
MR imaging.
Radiology
1989;
173:723729.
Cerofolini
E, Luchetti
R, Pederzini
L, et al.
15.
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Koman
LA, Poehling
GG,
Chronic
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16.
17.
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Arthroscopy
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MR
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ar-
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complex
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and arthroscopy.
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SP, Weiland
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RJ, Quinn
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ra-
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Volume
16
Number
1