Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons’ experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through ‘snow-balling’ until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V

1 Abstract 1 2 There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this 3 study was to investigate wrist surgeons' experiences and perceptions regarding treatment of 4 triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-5 making. A purposive sample of consultant wrist surgeons (n=10) was recruited through 'snow-6 balling' until data saturation was reached. Semi-structured interviews were conducted, digitally 7 recorded and transcribed verbatim. Two researchers independently analysed data using an 8 iterative/thematic approach. Findings suggest that surgeons rely more on their own training and 9 experience, and patient-related factors such as individual expectations, rather than on published 10 material, to inform their decision-making. Current classification systems are largely considered to 11 be unhelpful.

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This study adopted a qualitative methodological approach. This allows the exploration of 49 experiences, perceptions, meanings, beliefs, attitudes and processes to understand how phenomena 50 of interest are socially constructed (Hansen, 2006). Semi-structured interviews allow in-depth 51 investigation of a topic of interest using a set of pre-determined open questions informed by existing 52 knowledge, for example, experience and published research (Grbich, 1999). They also provide 53 flexibility to pursue new themes as they arise, acknowledging that the researcher does not know all 54 the questions before the start of the study (Rice and Ezzy, 1999). Although time-consuming, this 55 allows the exploration of in-depth accounts and the identification of new topics of interest, which is 3 not feasible with a questionnaire or structured interview. This is an iterative process, with ongoing 57 reflection to 'mature' the interview structure over the course of the interview period with 58 accompanying adaptation of the interview guide (Hansen, 2006). In this study, qualitative semi-59 structured interviews were used to investigate experts' perceptions and experiences regarding the 60 management of TFCC injuries and explore the rationale behind clinical decision-making in a UK 61 setting.

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To identify the initial questions for the interview guide, a review of publications on the management 63 of TFCC tears was carried out with the help of an information specialist, who developed the search 64 terms (Table 1); this identified a range of management choices, uncertainty around best practice, 65 and a lack of clear empirical evidence for any particular approach.

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The initial semi-structured interview guide was developed using this information and the experience The researcher (VR) obtained written consent and conducted, digitally recorded and transcribed 81 verbatim all interviews. Data collection and analysis was an iterative and emergent process; new 82 themes were added to the interview guide as they arose and recruitment stopped once 'saturation' 83 of emerging themes was achieved. Data saturation is considered the point at which no new themes 84 arose from the data (Bryman, 2004;Strauss and Corbin, 1998), suggesting that further interviews 85 would be unlikely to add significant information.

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Participants were allocated 4 weeks to reply to the recruitment email. Two to three participants 87 were recruited at a time and their interview data were analysed before further recruitment. No new 88 themes arose during analysis of the eighth and ninth interviews. To confirm with confidence that 89 data collection had reached saturation point, two further potential participants were emailed but 90 only one replied. This was the only time in the recruitment process when a reply was not received. It 91 was evident, however, that data saturation had been achieved after the tenth interview as this was 92 the third consecutive time that no new themes had arisen during data analysis, and therefore no 93 further recruitment was required.

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Data were analysed independently by two authors (VR, AF) using a thematic analysis: "a method for 95 identifying, analysing and reporting data" (Braun and Clarke, 2006). This approach involved six 96 stages starting with familiarization with the data (stage 1), followed by the identification of 97 recurring areas of interest, known as 'themes' (stage 2). Transcripts were then re-read and an   The importance of correctly identifying incidental degenerative TFCC lesions, which may represent 167 normal age-related changes in older patients with ulnar-sided wrist pain, was discussed (n=3).

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Increasing age, per se, was not considered a contraindication to treatment but the importance of 169 recognizing normal variants was emphazised to avoid unnecessary procedures:  210 "I suspect that in central tears, the pain is caused by a degree of impaction…I guess its ulnocarpal 211 impaction, being an impingement-type problem I suspect, but, we don't know" (P7).

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"Why that hurts, I don't know I'm assuming it's synovitis because the discs shouldn't hurt" (P1).

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Perceptions of the natural history and long-term consequences of chronic DRUJ instability also 276 influenced the choice between surgical or non-surgical management.

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"My concern about a chronically unstable joint is that over

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As far as we know, this is the first study to address TFCC injury management through a qualitative 426 interview approach. It explored the rationale behind clinical decision-making in TFCC management.